Treatment of Sleep Apnea and Snoring in Turkey

Sleep apnea is a serious sleep disorder in which breathing stops for a few seconds, and sometimes longer, then resumes, repeatedly throughout the night, often without the patient being aware of it. Its most prominent signs are loud snoring and persistent daytime fatigue despite sleeping enough hours. Snoring may seem harmless, but in some cases it is a warning sign of an airway obstruction that requires careful examination and diagnosis. If left untreated, the condition may raise the risk of high blood pressure, heart disease, and stroke. For this reason, many patients travel to Turkey for specialized evaluation at sleep centers and appropriate treatment, whether with devices or surgery, by experienced physicians.

Types of Sleep Apnea

Sleep apnea is divided into three main types, each with a different cause and treatment approach:

• Obstructive sleep apnea (OSA): The most common type. It occurs when the throat muscles relax during sleep, narrowing or blocking the airway and preventing air from reaching the lungs, even though the body continues trying to breathe.
• Central sleep apnea (CSA): Here the problem lies in the brain itself, which fails to send the correct nerve signals to the breathing muscles, so respiratory effort briefly stops. The airway is not necessarily blocked in this type.
• Complex sleep apnea: Also known as treatment-emergent central sleep apnea. It appears in some patients with obstructive sleep apnea whose disorder shifts to the central type after starting continuous positive airway pressure (CPAP) therapy, and it is usually diagnosed through a sleep study.

Symptoms of Sleep Apnea and Snoring

The symptoms of obstructive and central sleep apnea are largely similar, so it can be difficult to distinguish between them without a specialized examination. People around the patient often notice some of these signs before the patient does. Symptoms are divided into those that occur during the night and those that appear after waking.

Symptoms during sleep:

• Loud, frequent snoring.
• Short pauses in breathing, which your bed partner may notice.
• Sudden awakening with a sensation of choking or gasping for air.
• Difficulty staying asleep, or recurrent insomnia.

Symptoms during the day:

• Dry mouth upon waking.
• Morning headache.
• Severe daytime sleepiness, even after sleeping enough hours.
• Poor concentration and difficulty paying attention.
• Irritability and mood swings.

You should see a doctor if loud snoring is frequent and accompanied by daytime fatigue, or if your bed partner notices pauses in your breathing. Early diagnosis reduces the risk of complications and makes treatment easier and more effective.

Causes of Sleep Apnea and Snoring

The mechanism differs for each type of sleep apnea, and so do the causes.

Causes of Obstructive Sleep Apnea

During sleep, the muscles at the back of the throat relax. These muscles support the soft palate, tongue, tonsils, side walls of the throat, and uvula. With this relaxation, the airway narrows or closes during inhalation, so the body does not get enough air and blood oxygen levels drop.

The brain then senses danger and briefly wakes the sleeper so that the airway reopens. These awakenings are so brief that the patient does not remember them in the morning. They may be accompanied by snoring, choking, or gasping. This cycle can repeat 5 to 30 times per hour or more throughout the night, depriving the patient of restorative deep sleep, which is why they feel tired even after a long night’s sleep.

Causes of Central Sleep Apnea

This type is less common. Its cause is not a blocked throat but a disruption in communication between the brain and the breathing muscles. The brain does not send the necessary signals to them, so respiratory effort stops briefly. The patient may wake up feeling short of breath, or have difficulty falling or staying asleep.

This type is often associated with other medical conditions, such as heart disease or stroke, so its diagnosis requires a broader evaluation.

Risk Factors for Sleep Apnea

Sleep apnea can affect anyone, even children, but certain factors increase the likelihood of developing it.

Risk Factors for Obstructive Sleep Apnea

• Excess weight: Obesity is one of the most important causes, as fat accumulation around the neck and throat can narrow the upper airway and obstruct breathing.
• Narrow airway: The throat may be narrow for genetic reasons, or because of enlarged tonsils and adenoids (common in children), and it is also seen in people with thick necks.
• Sex: Men are two to three times more likely to be affected than women, but the risk in women rises with weight gain and after menopause.
• Advancing age: The prevalence increases among older adults.
• Family history: Having a relative with the condition increases your likelihood of developing it.
• Alcohol and sedatives: They relax the throat muscles and worsen the obstruction.
• Smoking: Smokers are about three times more likely to develop the condition than non-smokers, because smoking increases inflammation and fluid retention in the upper airway.
• Nasal congestion: Whether due to allergies or the structure of the nose, difficulty breathing through the nose raises the risk.
• Associated conditions: Such as congestive heart failure, high blood pressure, type 2 diabetes, polycystic ovary syndrome, hormonal disorders, and a previous stroke.

Risk Factors for Central Sleep Apnea

• Advancing age: Particularly in middle age and beyond.
• Sex: It is more common in men than in women.
• Heart disease: In particular, congestive heart failure.
• Opioid medications: The riskiest are long-acting types such as methadone.
• Stroke: Whether past or recent.

Complications of Sleep Apnea

Sleep apnea is a serious medical condition, and its effects are not limited to sleep quality but extend to the heart, metabolism, liver, and daily life.

Complications of Obstructive Sleep Apnea

• Severe fatigue and daytime sleepiness: Repeated awakenings at night deprive the body of the deep sleep that renews its cells. This results in severe drowsiness, poor concentration, and irritability, and the patient may fall asleep at work, while watching television, or even while driving. As a result, the likelihood of traffic and workplace accidents rises. Mood swings or depression are also common. In children and adolescents, the disorder may appear as poor school performance or behavioral problems.
• High blood pressure and heart disease: Sudden drops in oxygen levels during the night raise blood pressure and strain the heart and blood vessels. They may also increase the likelihood of heart attacks, stroke, and heart rhythm disorders such as atrial fibrillation. In patients with heart disease, repeated episodes of low oxygen may cause life-threatening arrhythmias.
• Type 2 diabetes: The condition increases the likelihood of insulin resistance and diabetes.
• Metabolic syndrome: A cluster of high blood pressure, high cholesterol and blood sugar, and a large waist circumference, associated with an increased risk of heart disease.
• Surgery and anesthesia complications: Affected individuals are more prone to breathing problems after major surgery, especially with anesthesia or when lying on the back. Therefore, you should inform your doctor about your condition and how you are treating it before any operation.
• Liver problems: Abnormal liver function test results may appear, and the condition may be linked to non-alcoholic fatty liver disease and liver scarring.
• Effects on the bed partner: Loud snoring deprives the person sleeping next to you of rest, and they may be forced to sleep in another room.

Complications of Central Sleep Apnea

• Severe fatigue: Repeated awakenings make sleep unrefreshing, so the patient suffers from daytime sleepiness, irritability, and poor concentration, and may fall asleep at work or while driving.
• Cardiovascular problems: Sudden drops in oxygen affect heart health and may increase the likelihood of rhythm disturbances, especially in people with heart disease.

Prevention of Sleep Apnea

Sleep apnea cannot be prevented in everyone, but addressing risk factors reduces the likelihood of developing it and eases breathing problems during sleep.

To prevent obstructive sleep apnea:

• Lose excess weight: One of the most effective steps, as it reduces the pressure of fat on the upper airway.
• Treat nasal congestion: Whether caused by allergies or a structural nasal problem, a clear nose makes breathing easier during sleep.
• Limit alcohol and sedatives: They relax the throat muscles and worsen the obstruction.
• Quit smoking: Smoking increases inflammation and fluid retention in the upper airway.

To prevent central sleep apnea:

• Reduce the use of opioid medications, especially long-acting ones, under a doctor’s supervision.
• Follow up on heart disease: If you have congestive heart failure, consult a specialist and monitor your condition regularly.

Most importantly, do not ignore symptoms such as loud snoring and persistent daytime sleepiness, as early detection makes treatment easier and reduces the risk of complications.

Diagnosis of Sleep Apnea and Snoring in Turkey

Diagnosis begins with a discussion of your symptoms and a review of your medical history for sleep disorders. Observations from your bed partner are helpful here, as they are often the ones who notice the snoring and pauses in breathing. The doctor then refers you to a sleep disorders center, where a sleep medicine specialist performs a more detailed assessment.

Tests Used in Diagnosis

• Sleep study (polysomnography): The body is connected to a device that monitors breathing patterns during sleep and measures heart, lung, and brain function, arm and leg movements, and blood oxygen levels. It is usually performed overnight at the center, especially if central sleep apnea is suspected.
• Home sleep tests: Simplified devices used at home, which typically measure heart rate, oxygen level, and airflow. They may not detect every case, so the doctor may recommend a full sleep study even if the home test result is normal.

Determining Severity

The severity of the disease is measured by the apnea-hypopnea index (AHI), which is the number of pauses or reductions in breathing per hour of sleep. The disease is generally classified as mild (5 to 15), moderate (15 to 30), or severe (more than 30), and the treatment plan is based on this classification.

Additional Tests and Referral to Other Specialties

• Ear, nose, and throat (ENT) specialist: To rule out obstructions in the nose or throat. Drug-induced sleep endoscopy (DISE) may be performed to pinpoint the site of obstruction, especially before considering surgery.
• Cardiologist or neurologist: To investigate the causes of central sleep apnea.

Treatment of Sleep Apnea and Snoring in Turkey

The choice of treatment depends on the type and severity of the disorder and the patient’s general health. In mild cases of obstructive sleep apnea, the doctor may recommend lifestyle changes alone, such as weight loss, quitting smoking, and changing sleeping position, along with treating nasal allergies if present. If symptoms do not improve, or if the condition is severe, other options are available, including devices that keep the airway open, and surgery may be needed in some cases.

First: Treating Obstructive Sleep Apnea with Devices

Many patients are treated successfully with positive airway pressure or oral appliances, which help prevent breathing pauses and increase daytime alertness and activity.

• Continuous positive airway pressure (CPAP): The most common and reliable treatment. The device delivers air at slightly higher than ambient pressure through a mask during sleep, keeping the upper airways open, so snoring disappears and breathing pauses stop. Some patients find it uncomfortable at first, but most get used to it over time and with adjustments to the mask straps. You may need to try more than one type and size to find the most suitable. Do not stop using the device on your own; instead, consult your doctor to discuss possible adjustments. If snoring returns despite consistent use, or if your weight changes significantly, the pressure settings may need to be adjusted.
• Other positive airway pressure devices: If CPAP does not suit you, there is APAP, which adjusts the pressure automatically during sleep, and BPAP, which provides higher pressure during inhalation and lower pressure during exhalation.
• Oral appliances: Fitted in the mouth to keep the throat open, and some work by pushing the lower jaw forward. They are easier to use but generally less effective than CPAP, and are more suitable for mild cases of snoring and apnea. After the device is fitted, it requires follow-up with a dentist several times in the first year, then periodically.
• Myofunctional therapy: Exercises that strengthen the upper airway muscles and reduce narrowing during sleep. They can be combined with other treatments.

Second: Medications for Obstructive Sleep Apnea

The U.S. Food and Drug Administration (FDA) has approved tirzepatide for the treatment of obstructive sleep apnea in people with obesity. Clinical trials have shown that it reduces the number of breathing pauses and improves oxygen levels during sleep. It is given as a weekly injection, and its side effects include nausea, diarrhea, vomiting, constipation, and abdominal pain. It is not recommended for people with medullary thyroid cancer or a family history of it, or multiple endocrine neoplasia syndrome type 2. The doctor prescribes it after evaluating the patient’s condition, and it should not be used without medical supervision.

Third: Surgical Treatment of Obstructive Sleep Apnea

Surgery is usually not the first option; it is generally recommended to try other treatments for at least three months before considering it. However, it may be an appropriate first option for a small group of patients with specific structural problems of the jaw. The options include:

• Tissue removal (uvulopalatopharyngoplasty): The surgeon removes some of the tissue at the back of the mouth and top of the throat, often along with the tonsils and adenoids. It is successful in reducing the vibration of throat structures that causes snoring, but it is less effective than CPAP and is not considered a reliable treatment for obstructive sleep apnea. A less invasive option is tissue reduction using radiofrequency energy, which may suit those who cannot tolerate CPAP or oral appliances.
• Maxillomandibular advancement: The jaw is moved forward, away from the other facial bones, which widens the space behind the tongue and soft palate and reduces the likelihood of obstruction.
• Hypoglossal nerve stimulation: A device is implanted in the chest that stimulates the nerve controlling tongue movement, keeping the tongue in a position that allows the airway to stay open. It is usually used when non-surgical treatments fail.
• Bariatric (weight-loss) surgery: It may reduce snoring and help treat the condition by relieving pressure on the airway.
• Tracheostomy: A rare procedure used when other treatments have failed in cases of severe, life-threatening apnea. The surgeon creates an opening in the neck and inserts a tube through which the patient breathes at night, bypassing the obstruction in the throat.

Fourth: Treatment of Central Sleep Apnea

Treatment of this type differs from that of obstructive apnea, because the problem lies in brain signaling and breathing control rather than throat obstruction. The doctor determines the appropriate option based on the underlying cause:

• Treating associated medical conditions: Causes of this type include heart disease and neuromuscular disorders, and treating these conditions may improve breathing during sleep.
• Positive airway pressure devices: The doctor may recommend a CPAP or BPAP device. There is also the recently approved adaptive servo-ventilation (ASV) device, which recognizes and stores your normal breathing pattern, then adjusts the pressure after you fall asleep to regulate breathing and prevent pauses. It may suit some patients with treatment-emergent central sleep apnea, but it is not recommended for those with severe heart failure.
• Supplemental oxygen: Using oxygen during sleep may benefit some patients.
• Medication adjustment: The doctor may prescribe a medication that helps control breathing, such as acetazolamide. If medications the patient is taking worsen the condition, such as opioids, the doctor may change them or adjust the dosage.
• Phrenic nerve stimulation: A stimulator is implanted in the chest that targets the nerve controlling the movement of the diaphragm (the phrenic nerve). When a pause in breathing is detected, it stimulates the nerve to restore breathing.

Advantages of Sleep Apnea and Snoring Treatment in Turkey

Many Arab patients travel to Turkey for the treatment of sleep apnea and snoring because it offers diagnosis and treatment in one place, with a standard of medical care that rivals that of leading countries. The main advantages of treatment there include:

• Comprehensive diagnosis in a single trip: Major hospitals house ENT, pulmonology, sleep medicine, and cardiology clinics, so the required tests and consultations can be completed in the same visit without traveling between separate locations.
• A variety of treatment options: From devices (CPAP and BPAP) and oral appliances to different surgical procedures, allowing the doctor to choose the plan best suited to your condition rather than a one-size-fits-all treatment.
• Experienced physicians: ENT specialists and maxillofacial surgeons in Turkey treat large numbers of international patients, which gives them extensive practical experience.
• Hospitals with international accreditation: A large number of Turkish hospitals hold Joint Commission International (JCI) accreditation and other accreditations, and adhere to quality and patient safety standards.
• Reasonable cost: Treatment costs in Turkey are relatively lower than in many European and Gulf countries, with comparable quality, especially for surgical procedures.
• Services for international patients: Hospitals have dedicated international patient offices, with reception services, interpreters, and coordination of accommodation and appointments.
• Ease of travel: Its proximity to Arab countries and the abundance of direct flights make it easy to reach.