Snoring and obstructive sleep apnoea

Do you snore? You're not alone. Up to 40% of adults snore

Although annoying for your partner, most snorers don’t have other health issues. Having said that, you may be a handful of people (4% or so) who suffer with obstructive sleep apnoea (OSA); this, unlike “simple” snoring, can be a severe threat to health.

Why do we snore?

The snoring noise is created by turbulence as air flows through the nose, throat and voice-box. Turbulence is created by a narrowing or floppiness in one of these areas.

Here are some of the commonest causes:

A narrowing in the nose caused by a bend in the septum (the cartilage wall that divides the nasal cavity into two) or enlarged turbinates.Turbinates are scroll shaped bones, coated by a moist lining on each side-wall of the nasal cavity. Turbinates are commonly enlarged in allergic rhinitis, for example with hay fever or dust mite allergy

Nasal polyps and inflammatory stimulants such as chronic infection and irritant chemicals can cause nasal and sinus inflammation (rhinosinusitis) that may also narrow the nasal passages

At the back of the nose, the adenoids can be enlarged, particularly in children

A blockage in the nose can indirectly worsen snoring and OSA by forcing you to open your mouth and “mouth breath” whilst asleep; this pushes the tongue further back to obstruct the airway

An elongated and floppy soft palate produces a characteristic rattling noise

Enlarged tonsils or an enlarged back of the tongue are very important causes of snoring and OSA

Weight gain leads to fat deposition in the neck and tongue

As we age, the tone of the throat muscles decline. This muscular tube tends to collapse when breathing in; made worse if there’s another pre-existing cause of obstruction

Some people’s anatomy predisposes them to airway obstruction, for example if you have a small jaw bone or under developed cheekbones

Sometimes a fairly rapid and new onset of snoring and airway obstruction may be due to a tumour growth in the base of tongue or the voice box

What is obstructive sleep apnoea?

This term refers to the situation where air flow ceases or dramatically falls for more than 10 seconds at a time during sleep as a consequence of a blocked upper airway.

For good health, you are allowed up to 5 such episodes per hour, but any more than this is medically defined as OSA. Don’t worry, the body won’t allow you to stop breathing for too long, as a lack of oxygen triggers the brain to send signals to the breathing muscles, forcing a gasp and a sharp intake of breath.

As you can imagine, this is not only very disruptive to your sleep, but in some people these obstructive episodes are so frequent that the chronic lack of oxygen strains multiple body systems.

What are the symptoms of OSA?

OSA is an extremely common problem in people who are overweight and obese; but it can occur in thin people
Cessation of breathing during sleep
Gasping or choking throughout your sleep
Waking up with night sweats and a racing heart
Unrefreshed sleep with headache
Daytime tiredness and inability to think
Waking up multiple times throughout the night to pass urine.
A reduction in sex drive

If OSA is not treated over a period of time, there is a risk of acquiring serious chronic illnesses such as high blood pressure, diabetes and heart disease. Your stroke risk is also elevated.

How is OSA diagnosed?

If you score highly on a specific questionnaire such the Epworth sleep questionnaire, this is suggestive of you suffering with disordered breathing during sleep.

I will perform a full head and neck examination, including an assessment of mouth opening and a look at your nasal airway, your throat and your voice box with the aid of a high-definition flexible camera.

The sleep study

The main way of diagnosing whether you have a OSA is via a sleep study.

There are essentially two types:

A portable device you take home that records your oxygen saturation throughout your sleep, via a probe placed on your finger. Newer devices can also measure nasal airflow and chest movements.

Full in-patient polysomnography. If there is doubt about your diagnosis, a comprehensive sleep study will be recommended. This requires you sleep in the hospital, where we can measure numerous different breathing and movement parameters. This is especially important to exclude certain neurological conditions that may cause similar symptoms of OSA.

The drug induced sleep endoscopy (DISE)

In my practice this is a key investigation.

If we contemplate surgery for your snoring or OSA, I want to examine how your airway behaves during sleep.

This is achieved by titrating small quantities of anaesthetic agent, just enough to put you to sleep and initiate your snoring, but not too deep so you are still able to breath unassisted. I will then pass a flexible camera through the nose to inspect all the anatomical areas of your upper airway that might be contributing to the obstruction. Often this gives a very different picture to a similar examination whilst you are awake.

This simple procedure may be combined with an operation on a fixed, structural source of obstruction such as a deviated nasal septum or enlarged turbinates.

We will review the recording of your airway together and this will be used to tailor the surgery I need to perform on your unique anatomical problem(s).

How will I treat your snoring or OSA?

The single most important thing you can do is to try and lose weight if you are overweight. Sometimes this is extremely difficult and I may recommend a referral to a dietician or even a bariatric surgeon.

Improving you sleeping position may help. Sleeping on the side puts the tongue in a more forward position than when you lie on your back.

Treating any nasal conditions with medical or surgical therapy will not only improve the snoring but makes it easier for you to sleep with your mouth closed. This also draws the tongue forward, opening the up throat.

A mandible advancement splint (MAS) is essentially a gum shield designed to be worn during sleep. It holds the lower jaw in a relatively forward position in comparison to the upper jaw. Because the tongue is attached to the lower jaw, it is pulled forward too. These devices may be custom built for comfort.

CPAP

The current gold standard treatment for OSA is continuous positive airway pressure (or CPAP). This is pressurised air that is delivered through a nasal or face mask that splints open the airway during your sleep. To be effective, it needs to be used ideally for at least 7 hours a night. Some patients can’t tolerate it and for others it causes troublesome side effects or can’t achieve the pressure requirements to reverse the airway obstruction.

People who cannot tolerate CPAP are a particularly difficult group of patients to manage.

I have a unique interest in these patients and have successfully managed to negate the need for use of CPAP in a high percentage of surgically treated patients.

Transoral robotic surgery to the base of tongue

Surgery in the context of OSA aims to:

Open the nasal and throat anatomy to improve delivery of CPAP
Potentially eliminate the need for CPAP altogether

Traditionally, tongue base obstruction has been the most difficult area to manage surgically, mainly because it’s a difficult area to access through the mouth.

In my opinion, the transoral robotic surgical approach comes into its own here. The Davinci© robotic set up I use, gives me a fantastic view and access to the back of the tongue, enabling me to deliver a safe and focused resection of the offending obstructing tissue.

My team has one of the largest surgical experiences in the UK of managing OSA patients with robotic surgery.

Thus far we have managed to reverse OSA (and therefore need for CPAP) in over 75% of carefully selected patients.

Other operations?

A small percentage of patients will not be suitable for any of the minimally invasive treatment options I have just described.

These patients may be benefit from “open” procedures that alter the tongue and voice box position (hyoid or laryngeal suspension) or indeed an alteration in the structure of their jaw bones (maxillomandibular advancement) to ultimately increase space in their airway.

These advanced procedures can be extremely successful, but they are more invasive and as such have higher side effect profiles.

Are there other novel treatments?

I am continuously looking to try and offer my patients state-of-the-art innovations in surgery.

One new innovation in OSA management that is gaining popularity in Europe and the USA is hypoglossal nerve stimulation. Very simply, when switched on, a hypoglossal nerve stimulator is like a pacemaker that is designed to monitor your breathing. By way of electrodes attached to specific tongue nerves, an electric signal is sent to the tongue at the precise moment you breath in, causing the tongue to move forward to open up the throat.

It is a device that is not widely available in the UK yet, but I hope that I may be able to offer this in the near future.

Watch this space!