Snoring and Obstructive Sleep Apnoea
Loud snoring can ruin a good night's rest, not only for the bed partner but also the snorer who is woken up by attempts to stop him (or her) snoring. This noise is normally generated in the throat, but its mechanism and treatment is actually extremely difficult to understand. Most doctors have had no training in this new field, and many ENT surgeons have actually never had experience with this difficult topic. Mr Vik Veer is one of two surgeons in the country who has been employed on the NHS specifically solely to treat Sleep Disordered Breathing. This page describes some of the aspects of this field, and will give you information about diagnosing and treating snoring and sleep apnoea.
Snoring and Obstructive Sleep Apnoea are conditions that are often considered to lie on opposite ends of the same spectrum. This spectrum is collectively known as Sleep Disordered Breathing.
Approximately 42% of middle-aged men snore on most nights, and roughly 4% of the population have Obstructive Sleep Apnoea (otherwise known as OSA), although most do not realise this. Even those who have been diagnosed with obstructive sleep apnoea, very few go on to be treated adequately.
Sleep apnoeas are when you stop breathing at night for a short period of time (about 10 seconds or so). This can happen in normal people, but in people with sleep apnoea, obstruction of breathing can happen over 5 times an hour. This means that these people partly wake up about once every 10 minutes whilst they sleep. People with sleep apnoea are unaware of the vast majority of these events, but occasionally bed partners will witness some of the more severe episodes as an obvious cessation of breathing. You can imagine what effect this has on someone who is unable to get a proper night’s rest if they are being woken up every 10 minutes at its most mildest form. Some people really suffer, and are woken up more than once a minute on average all night. This leads to disabling tiredness and terrible consequences to the body as it tries to deal with this problem.
A disease that lies between snoring and sleep apnoea on the spectrum is known as Upper Airways Resistance Syndrome (UARS). This entity has not been defined conclusively, but in simple terms these people do not completely stop breathing at night but there is a difficulty in breathing properly. Think of it as a very narrow airway that is difficult to pass air through with each breath. This typically produces a deep breathing noise at night rather than silent breathing. Upper Airways Resistance Syndrome is also treated on the NHS (in very few centres), as it also causes significant problems for patients. Mr Vik Veer believes that rather than it being on the same spectrum, UARS should be considered as a separate entity of its own, as these patients feel just as bad as some sleep apnoea patients.
Complications of Obstructive Sleep Apnoea
The reason why we treat UARS and sleep apnoea is because they cause huge problems for patients. Below are some of the problems caused by sleep apnoea. Research regarding UARS is still in the early stages and therefore there isn’t any solid data on this yet.
- Mental Slowness. Having sleep apnoea leads to a number of mental difficulties. One study, which looked at all the data on this subject, found that patients had impairment of inductive and deductive reasoning, attention, vigilance, learning, and memory. This means that patients with sleep apnoea are unable to think as clearly as before.
- Road Traffic Accidents. The most worryingly consequence of this difficulty in thinking clearly is seen as a worsening of people’s driving ability. You are 5-12 times more likely to have a road traffic accident if you have obstructive sleep apnoea. This risk of driving with sleep apnoea is becoming more of a public issue, as the DVLA have recently updated their guidance for these patients.
- Growth Hormone. Snoring is normally considered a nuisance and merely a social problem. There is more evidence that suggests that children who snore have reduced levels of growth hormone, they have a higher rate of neurocognitive disorders and it seems to affect the quality of a child’s life. Showing a problem in adults is much harder to investigate, but there are researchers actively looking into this.
- Depression. There is a 1.8 times risk of acquiring depression when you have sleep apnoea. Interestingly it seems depression may actually cause sleep apnoea as well, although the reasons for this haven’t been researched yet.
- High Blood Pressure. Most people with sleep apnoea have a higher blood pressure than before. Many sleep apnoea patients have what is known as resistant hypertension, meaning that their blood pressure is very difficult to control with the normal blood pressure medications. A large study known as the heart BEAT study stated that in cases of resistant hypertension, it is reasonable to investigate for sleep apnoea purely because it is a common cause of this problem (J Clin Sleep Med 2014 Walia). Treating obstructive sleep apnoea also leads to a reduction in blood pressure without requiring any antihypertensive medication. In some cases, Mr Vik Veer has to warn patients that when their sleep apnoea is being treated patients should be keeping a close eye on their blood pressure because it might go too low if they are on a lot of medication for it.
- Heart Failure. One study found that 50% of patients with heart failure also had obstructive sleep apnoea. Heart failure and sleep apnoea seem to be very closely linked. (Macdonald J Clin Sleep Med 2008)
- Stroke. Another study also showed that having sleep apnoea is risk factor for getting a stroke (hazard ratio 1.97). They also found that the higher the number of apnoeas each hour meant there was a higher risk of getting a stroke. (Yaggi N Engl J Med 2005)
- Heart Arrhythmias. The Sleep Heart Health Study found that there is a 5 fold increase in arrhythmias (Am J Respir Crit Care Med 2006). These are abnormal heart rhythm problems like AF (atrial fibrillation). Another study found that electrical reversal (cardioversion), of AF is 82% likely to fail if the patient has sleep apnoea. (Kanagala Circulation 2003)
- Weight Gain. It is extremely hard to lose weight when you have Obstructive Sleep Apnoea. We believe this is because the body is in a ‘stressed’ state, and therefore it reacts by holding on to fat. This is the caveman reaction in all of us preparing for a harsh winter. Mr Vik Veer’s approach in people who have a weight problem with sleep apnoea is just to go ahead with treatment. He has had excellent results this way in the long term, because just giving a little bit of help to these patients mean that they have more energy to go on and exercise and lose weight. Losing 10% of body weight generally translates to reducing snoring and sleep apnoea by 30%. Some people are unable to start this process until they have had a little bit of treatment to get them back on the right path. An honest clear conversation with a multimodal treatment approach to sleep apnoea is what Mr Vik Veer practices in his NHS and private work.
- Diabetes. Patients with sleep apnoea are more likely to have diabetes (European Sleep Apnea Cohort (ESADA) study. Chest 2014; Kent). Similar to high blood pressure, Mr Vik Veer suggests that patients keep a careful eye on their glucose levels during treatment as there is a chance that the diabetes will improve, and therefore patients should avoid the complication of taking too much medication and dropping their glucose levels too low.
- Cholesterol. Levels of fat in the blood also improve after treatment of sleep apnoea.
- Patients with sleep apnoea are more likely to seek medical attention, use medication, be unemployed, and have lower income levels. It was estimated that patients lost up to the equivalent of 12,000 Euros a year and their partners lost about 3000 Euros per year due to sleep apnoea. This is a massive drain on patients and the economy (Danish patient registry 2014 Sleep Medicine). 432 million pounds a year is estimated to be lost in the NHS due to untreated sleep apnoea. It seems incredible that more is not being done to draw attention to this problem and try and prevent these complications.
You are 5-12 times more likely to have a road traffic accident if you have obstructive sleep apnoea.
Symptoms of Sleep Apnoea
There are very few actual symptoms for Obstructive Sleep Apnoea, which makes the disease very difficult to treat as very few people know that they are suffering. The list below gives an idea of some of the symptoms that sleep apnoea patients may have.
- Waking up in the morning feeling unrefreshed and still tired.
- Not getting a good night’s sleep.
- Being tired during the day, and nodding off more easily.
- Feeling mentally tired, difficulty in concentrating, and needing extra effort to stay alert.
- Waking up at night gasping or choking.
- This is because obstructive sleep apnoea leads to episodes of stopping breathing whilst you sleep. Some of these can be so bad that you need to actually fully wake up to start breathing again.
- Waking up at night to urinate.
- This is because a hormone is released from your heart when you wake up. This makes you go to the toilet in the mornings, whilst stopping you from passing water during the night. If however you are constantly partially waking up every hour, the effect is that some sleep apnoea sufferers wake up at night to urinate. Many mistakenly believe that they have a weak bladder or something similar.
- Sweating at night.
- Waking up with a headache in the mornings.
- Waking up with a dry or sore throat.
- Snoring leads to a vibration or flapping around of tissue at the back of the throat. Repeated trauma to this tissue leads to discomfort which is normally felt in the morning.
- Heart Burn / indigestion.
- Symptoms such as acid burn reflux, feeling of a lump in your throat, clearing your throat all the time, noticing that your voice becomes hoarse if you talk for too long at a time or during singing, and occasional spasms of your throat during swallowing.
- Having a reduced sexual drive.
- Feeling depressed, anxious, or irritable.
432 million pounds a year is estimated to be lost in the NHS due to untreated sleep apnoea.
Another way of trying to find out if you have Sleep Apnoea is to use the STOPBANG Questionnaire, A Simplified version is provided below.
S – Do you snore loudly (loudly = can someone hear your through a closed door?)
T – Are you tired during the day?
O – Has anyone observed you stop breathing at night?
P – Do you have or are you being treated for high blood pressure?
B – Is your Body Mass Index (BMI) greater than 35?
A – Are you older than 50?
N – Is your shirt collar size greater than 17 inches (16 inches for a woman)?
G – Are you male?
You get one point for every question you say 'YES' to. The total score determines your risk of having Sleep Apnoea
- If you score 2 or less you are low risk.
- If you score 3 to 4 you are intermediate risk.
- Greater than 4 you are high risk for having sleep apnoea.
- If you score 2 in any of the 'STOP' questions AND if you are male OR have a wide neck OR have a BMI greater than 35, then you actually have a high risk.
Mr Vik Veer is developing a new way of assessing if you have Obstructive Sleep Apnoea, which is called the STAMP Questionnaire. This provides a score out of 100, with the higher scores meaning you have a higher chance of that you are suffering from symptoms that you get in Obstructive Sleep Apnoea. This questionnaire is still in the research phase of development.
The current only true way of working out if you have obstructive sleep apnoea, is to undergo a Sleep Study otherwise known as a Polysomnogram. This is basically a test which monitors you whilst you sleep and works out if you have obstructive sleep apnoea or not. The test at its most simplest will give an AHI result. This is the number of times you stop breathing on average for every hour you sleep.
- An AHI below 5 is considered normal in adults.
- AHI 5-15 is mild obstructive sleep apnoea
- AHI 15-30 is moderate obstructive sleep apnoea
- An AHI greater than 30 is considered to be severe obstructive sleep apnoea
Unfortunately the overall AHI score can be misleading as it might be that patients only get obstructive apnoeas when lying on their back. If on the night of the sleep study you happened to mainly sleep on your side this would mean the total average AHI for the whole night would dip below 5 giving the false impression that they are normal. A close examination of the entire sleep study is required to make sure that nothing is missed.
If you are thinking of seeing Mr Vik Veer for a private consultation, it would speed up the process if you bring your full sleep study report with you to the appointment. Please note that for adults a pulse oximetry monitor does not provide adequate enough information. Either a full polysomnogram or a good quality home sleep study is required. Mr Vik Veer prefers the NOX T3 sleep study device if possible.
For children, a sleep study is not always necessary.
If you do not have a sleep study report or have never had one, then Mr Vik Veer will arrange one with you or refer you to a suitable centre for testing. Normally a home NOX T3 sleep study is what is required, however if there is a possibility that there is another sleep problem (other than just sleep apnoea), then a full overnight polysomnogram is needed. This decision can be made at consultation if needed.
Treatment for Obstructive Sleep Apnoea
There are different types of treatment for obstructive sleep apnoea, some require surgery, and some do not:
Continuous Positive Airways Pressure Mask (CPAP)
This is when a mask is fitted to your face each night to drive air into your lungs whilst you sleep. This is an excellent treatment choice for those who can tolerate it. Unfortunately about 50% stop using it after the first week and 83% stop using CPAP long term (Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008 Feb 15;5(2):173-8). Most patients have difficulty coping with the feeling of claustrophobia and finding that the device itself wakes them up at night. Minimal compliance with CPAP is defined as using it for 4 hours a night 70% of the time. However for CPAP to be effective, you should use it every night for at least 7.5 hours, otherwise you’ll still suffer with the complications of sleep apnoea. For those patients that only manage to use it for 4 hours a night 70% of the time research has shown that the AHI in these patients is still about 11.91 on average, which is still defined as Sleep Apnoea. (Stuck BA, Leitzbach S, Maurer JT. Effects of continuous positive airway pressure on apnea-hypopnea index in obstructive sleep apnea based on long-term compliance. Sleep Breath. 2012 Jun;16(2):467-71)
In some European countries patients are warned that if they don’t use the CPAP device that their driving licenses will be confiscated. This is not the case in the UK at the moment. Please see the current DVLA page on sleep apnoea.
The main advantage of CPAP is that there are very few side effects if you can tolerate the CPAP device. Also using CPAP before undergoing surgery makes the operation much safer and Mr Vik Veer will explain that if using CPAP is a possibility, that patients should continue CPAP even during surgical treatments. The plan would be to slowly come off CPAP and sleep without it once all the treatment is completed.
Mandibular Advancement Devices
These are basically gum guard like devices that bring your lower jaw forward. If your tongue causes most of your obstruction during sleep, then this should allow you to breathe better at night. There are again some difficulties with being able to tolerate this device in your mouth all night, and some patients complain of tooth loosening and sore jaw joints in the mornings. These devices may be used with CPAP as well.
Surgery for Snoring and Obstructive Sleep Apnoea
If patients cannot tolerate or dislike the idea of CPAP or Mandibular Advancement Devices, then the only other option is surgery.
From the back of the nose to the voice box, there are many different problems in the throat that can cause snoring or Sleep Apnea. Therefore there are many different operations and every patient is different. No one has the same problem and therefore there is no one operation that fixes everyone. In the past surgeons used one operation to try and cure sleep apnoea, but because it was only the correct operation for a small percentage of patients, only a few people gained benefit from it. Using modern surgical techniques we are now able to determine what is causing the problem in each case. Using this information Mr Vik Veer is able to select the correct operation for each patient.
An operation for the palate hardly ever cures sleep apnoea.
Drug Induced Sedation Endoscopy (DISE) This is when a very small amount of anaesthetic is given to drift a patient off to sleep. At a same time, a tiny fibreoptic telescope is used to visualise the throat whilst the patient is asleep. The whole procedure takes about 10 minutes or so, and the risk of complications is extremely low.
Currently DISE is the only way to find out where the snoring noise is coming from and what is causing the obstruction in the upper airway. Unfortunately all the other techniques for determining the cause of obstruction only really tell you the approximate anatomical level rather than the actual problem. For example a large uvula, a lateral pharyngeal wall collapse, a tongue base obstruction, tonsillar obstruction or a epiglottis trapdoor problem all occur at roughly the same level. At this level they can all cause problems simultaneously and to a different degree in each individual. That is why Mr Vik Veer uses DISE to identify the actual problem and know how to treat it. The quality of DISE recordings have improved considerably in 2016 with newer techniques for this investigation.
Mr Vik Veer has spoken internationally about DISE, and has introduced a new classification system for its use. DISE is a difficult technique and Mr Vik Veer has conducted an international survey on DISE and found that the understanding of this procedure in the UK is poor. He is a world expert in this field, and will be happy to discuss this technique in more detail with you if you wish.
There are a multitude of operations that can help patients with snoring and sleep apnoea, and they range from the minimally invasive to the more extreme. A brief outline of these operations is provided below:
Improving the flow of air through the nose does not actually improve snoring or obstructive sleep apnoea, and in some cases it actually makes snoring worse. This is because even though you now are able to breathe through your nose, it does not necessarily mean that you will automatically start breathing through your nose during sleep. breathing through the mouth becomes a habit for people, and so it is unlikely that you will preferentially use the nose to breathe even after surgery. In these cases, using a chin strap (a device to close the mouth at night), is enough to slowly convince you to breathe through the nose and hopefully reduce the volume of snoring to a socially acceptable level. Once the patient has habituated to breathing through the nose again during asleep, he or she should be able stop using the chin strap and carry on without it.
There are many different operations for the nose. Some operations (such as turbinate reduction) can be done under local anaesthetic, and have very few complications. Other operations such as a septoplasty (where the central partition of the nose called the septum is straightened up so you can breathe equally on both sides), and polypectomy (where polyps are removed from the nose to help breathe past them), can take longer to perform, and will probably require a few days off work. Choosing the correct operation is a difficult balance, and sometimes can only be decided during the operation itself. Most of the time Mr Vik Veer will choose the least invasive option to help patients breathe better.
These operations include any operation involving the palate or uvula (the dangly thing at back of your throat). This includes using a laser or other techniques to stiffen or reduce the size of the palate. In the past surgeons only used these operations to try and treat Obstructive Sleep Apnoea. This was always bound to fail as the palate is a flap and can close the entrance to nose OR mouth. What the palate cannot do is block the nose AND the mouth at the same time. So if the palate is blocking the nose, the patient will just open their mouth and breathe through their mouth instead or vice versa. This will lead to snoring certainly, but the patient will still be able to breathe meaning that they cannot get Obstructive Sleep Apnoea.
Occasionally the uvula, may be involved in blocking the airway. The uvula can drop down behind the tongue where the majority of obstruction in sleep apnoea occurs. The uvula may block off the last 5%-10% of an already severely constricted airway. So in the past when surgeons just operated on the palate, removing the uvula (which is a part of these palatal operations), only opens a small amount of the airway. This is why some sleep apnoea patients did initially get better after this operation, but normally this effect did not last for long. This led to recurrence of problems particularly in the long term.
With newer techniques recently developed, we are able to identify these issues and choose the correct operation for each patient.
In most cases sleep apnoea patients very little needs to be done to the palate, which means the pain from this operation is greatly reduced. Most people who snore without obstructive sleep apnoea have a problem with their palate. There are now various techniques to scar and stiffen the palate to make it more rigid and tight. This stops it vibrating so much, and therefore reduces the noise that it generates. Some operations cause minimal pain, but may take longer to have an effect. Mr Vik Veer will be happy to discuss the options with you as he has taught on international courses about these techniques.
Tonsils can obstruct the airway by meeting together in the middle and not allowing any air to pass. Sometimes even though tonsils look small inside the mouth, they can still have a large component at the back of the throat that can still cause significant problems breathing. So using DISE certainly helps in the investigation of these patients to decide if a tonsillectomy is required.
A tonsillectomy is a relatively quick operation taking less than 5-10 minutes on average. There are a number of ways of removing tonsils and more information about this can be found on the tonsillectomy page on this website. In brief, for Snoring and sleep apnoea patients, Mr Vik Veer normally uses a cold steel intra-capsular tonsillectomy technique for most patients. It isn’t possible to use a tonsillOTOMY approach in sleep patients as it still leaves tonsillar tissue behind and that can still lead to obstructive sleep apnea and snoring. In children an intracapsular tonsillotomy (coblation) approach is probably adequate in most cases. Discussing the pros and cons of different types of tonsil operations is a difficult balance, and Mr Vik Veer will be happy to discuss this with you and explain it all.
Lateral Pharyngeal Wall Collapse
In some patients (particularly in those with sleep apnoea and loud snoring), the lateral pharyngeal wall collapses down and obstructs the airway. This is the back wall of the throat you can see behind the tonsils and behind the uvula. In some severe cases you can even see a bulging of the tissue here behind the tonsils, which Mr Vik Veer calls ‘lateral wall cushions’, which is one of the signs that this area is a problem.
The back wall of the throat collapses down towards the back of the tongue and the back of the palate, sometimes completely blocking off the throat and causing Obstructive Sleep Apnoea. It is a difficult area to treat, and only a minority of surgeons in the world actively operate here.
Expansion Sphincter Pharyngoplasty is one of the operations that is used to remedy this problem, and there are several modifications to the original described technique. In short it uses some of the muscles in the back of the throat, and redirects them. By attaching these muscles in different locations the airway can be forced open rather than collapse upon itself. It is a powerful technique in the correct patients, and Mr Vik Veer has had complete cures (AHI<5), in some extremely severe sleep apnoea patients (AHI > 100!), with this operation.
There are a few other operations that can be used to treat this problem, many of these are being developed by Mr Vik Veer.
Tongue Base Operations
The tongue is a common reason why people have Obstructive Sleep Apnoea, and rarely snoring noise comes from here. The tongue falls back and blocks the throat, stopping breathing.
The tongue is extremely difficult to operate on, and therefore Mr Vik Veer has experience with a number of techniques to use so that he can individualise care for each patient. The least painful operation is radiofrequency ablation of the tongue base which stiffens and shrinks this area so patients can breathe past the obstruction. Coblation and robotic surgery of the tongue base are other techniques which reduces the volume of the tongue so that it doesn’t obstruct breathing. Mr Vik Veer is also leading research into a new implantable device that will be inserted into the tongue to stimulate it so that it doesn’t block the throat. This operation will be the first of its kind in the United Kingdom, and should be available once the results are verified.
There are a number of problems that may affect the larynx (also known as the voice box), and the epiglottic trapdoor is the most common of these. The epiglottis is used to divert food away from the voice box during swallowing so that food doesn’t go down the wrong way. In some patients the epiglottis collapses back into the voice box during breathing which completely blocks off the ability to breathe. This is one of the reasons in why CPAP actually makes these patients worse, rather than better. There are a number of other different problems of the larynx that can make breathing more difficult.
These are the very basics of the surgical options for snoring and sleep apnoea. Obviously there are a number of modifications and subtleties that are not included here. Most of the differences occur when a number of different obstructive problems occur simultaneously. In this situation, individualised treatment is needed, and Mr Vik Veer will explain this to you in detail.