Selection of videos for Snoring & Obstructive Sleep Apnoea
How Sleep Apnoea Should Be Treated
I explain (and also occasionally rant about) what I am
trying to achieve by trying to help people wth obstructive
sleep apnoea. I want to show waht my goal is and how I
think sleep apnoea treatment needs to change otherwise
slowly patients will disengage from medical services.
I also talk through step by step what my process is with
helping peolpe with sleep apnoea. I epxlain why I want
people to use CPAP and how I eventually hope to get them
off again.
Is AHI Enough? The Truth About Sleep Apnoea Diagnosis
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Inspire/Genio Implants for Sleep Apnoea - Where?
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Overview of Snoring & Obstructive Sleep Apnoea
This is simply an overview of Snoring & Obstructive Sleep Apnoea. If you want more information about a specific topic, please use the in
Understanding Sleep Disordered Breathing
What is Sleep Disordered Breathing?
Sleep Disordered Breathing (SDB) encompasses a range of conditions, including snoring and Obstructive Sleep Apnoea (OSA), that disrupt normal breathing during sleep. These disturbances can significantly impact the quality of sleep for both the individual and their bed partner.
Causes of Snoring and Sleep Disordered Breathing
Loud snoring is a common symptom of Sleep Disordered Breathing. The noise typically originates in the throat due to vibrations of the soft tissues. Despite its common occurrence, the underlying mechanisms and effective treatments for snoring can be quite complex and challenging to understand. Many medical professionals, including ENT (Ear, Nose, and Throat) surgeons, often lack specific training in this specialized area of sleep medicine. Prof Vik Veer is one of the few surgeons in the country employed by the NHS specifically to treat Sleep Disordered Breathing.
The Spectrum of Sleep Disordered Breathing
Sleep Disordered Breathing is a spectrum that ranges from simple snoring to severe Obstructive Sleep Apnoea (OSA). It's important to understand where you might fall on this spectrum to seek appropriate treatment.
Snoring: Approximately 42% of middle-aged men snore regularly. This condition can be disruptive but isn't always indicative of a more serious underlying issue.
Obstructive Sleep Apnoea (OSA): Affecting roughly 4% of the population, OSA is characterized by repeated episodes of complete or partial obstruction of the airway during sleep. This results in temporary cessation of breathing (apnoea) or shallow breathing (hypopnoea). Many people with OSA are unaware they have it, although it can have severe consequences if left untreated.
Upper Airways Resistance Syndrome (UARS): Upper Airways Resistance Syndrome (UARS) is another condition on the Sleep Disordered Breathing spectrum. Unlike OSA, individuals with UARS experience increased resistance to airflow in the upper airways without complete obstruction. This results in labored breathing and often produces a deep breathing noise rather than silent breathing. UARS can cause significant discomfort and similar symptoms to OSA, including daytime fatigue and disrupted sleep. Mr. Vik Veer suggests that UARS should be considered a separate entity due to its unique characteristics and impact on patients' well-being.
Obesity Hypoventilation Syndrome (OHS): is a breathing disorder that affects individuals with severe obesity. Basically there is too much weight pressing down on the chest at night and this results in an inability to take adequate breaths. This is characterized by inadequate ventilation leading to elevated blood carbon dioxide levels and reduced oxygen levels.
The Impact of Sleep Apnoea
Individuals with OSA experience multiple episodes of airway obstruction during sleep, leading to frequent awakenings. These interruptions can occur more than five times an hour, significantly disrupting the sleep cycle and leading to chronic fatigue. In severe cases, individuals may wake up more than once a minute throughout the night. The lack of restful sleep can have profound effects on overall health, contributing to cardiovascular issues, cognitive impairment, and decreased quality of life.
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.
What is a Sleep Study?
A sleep study, otherwise known as a polysomnography test is a device that monitors your sleep at night. Most sleep studies are performed to diagnose obstructive sleep apnoea, and occasionally Upper Airways Resistance Syndrome. Sometimes they can be used to diagnose other diseases such as Restless Legs Syndrome, or Epilepsy.
Sleep Studies are performed over one night and can be either performed at home or in a hospital. Normally if you are worried about Obstructive Sleep Apnoea or Upper Airways Resistance Syndrome, then a study performed at home is all you need. If your doctor suggests that you need a sleep study done in a hospital overnight, then they will be also checking for epilepsy (as they will require a video recording of the sleeping patient). Restless legs syndrome can be diagnosed at home, and does not require an inpatient stay, but often a video recording is very useful. A Sleep Study done in a hospital is often called a Polysomnography.
What is it like to have a Sleep Study?
A sleep study is a non-invasive test, and does not cause any pain or side effects. The device is a smartphone-sized box which is attached via elastic bands that gently wraps around your chest and stomach. There are a number of other cables that are needed to collect data:
There is a monitor that sits on your finger which monitors pulse rate and oxygen levels in your blood.
The elastic straps that go around your chest are there to monitor how hard you are trying to breathe at night.
The one around your stomach is compared to the one around your chest, and that provides information about people who are struggling to breathe at night (the chest and stomach move in different directions when someone is trying to breathe against a blockage).
There is sometimes a cable that runs around your nose and monitors the airflow at whilst you breathe. This is very important when you are trying to diagnose Upper Airways Resistance Syndrome.
There can be a number of other cables that lead to you head or legs to diagnose other conditions.
What is pulse oximetry?
Pulse oximetry is just the device that sits on your finger at night (monitoring heart rate and oxygen levels in the blood. Mr Vik Veer does not recommend the use of these devices as they are unable to detect most problems during sleep. It will only pick up very obvious severe sleep apnoea but in Mr Vik Veer’s experience it misses significant problems with sleep disordered breathing. Prof Vik Veer has met a number of people who have had a pulse oximetry test (which is mainly used by Respiratory teams who provide CPAP), who were then told that they have no problem after the test. When they go on to have a proper sleep study they find out that in fact they have a treatable sleep disorder which helps them with their tiredness and other symptoms. If you know you will only accept CPAP as a treatment option, then a pulse oximetry would be a reasonable choice.
Pulse Oximetry is often used for children in the NHS to work out if they should undergo an adenotonsillectomy to solve their sleep apnoea problem. Mr Vik Veer still advocates a proper sleep study even in children.
How can I get a Sleep Study done?
Mr Vik Veer provides a courier service where a state-of-the-art sleep study machine is sent directly to your home / workplace. You would then use the device that night in the comfort of your own bed, and then the courier will return the next day to pick up the device. This avoids having to travel into central London to pick up a device and return it by hand the next day. Because of the courier, this sleep study option is now a national service. Now anyone in the country is able to have a sleep study done whenever they wish. To get the results you may want to have a formal report written for you by Mr Vik Veer or if you prefer you can visit Mr Vik Veer in his London clinics to discuss the results face-to-face.
If you would like more information or to book in a sleep study please contact Mr Vik Veer via his team of secretaries:
Mr Vik Veer has the largest practice in the country for treating obstructive sleep apnoea with surgery. He operates on approximately 260 patients a year specifically for Snoring and Sleep Apnoea. He is the most experienced full time NHS consultant who has been employed specifically to treat sleep apnoea with surgery. He is also the only surgeon in the country fully funded on the NHS to carry out this work.
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.
Myofunctional Therapy
This is a useful new specialist therapy which is increasingly used as a treatment for snoring and sleep apnoea. It is often used in addition to other therapies, but because of the low risk it can be used for all patients.
Surgery for Snoring and Obstructive Sleep Apnoea
If patients cannot tolerate or dislike the idea of CPAP or Mandibular Advancement Devices, then another 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 Prof Vik Veer is able to select the correct operation for each patient.
Drug Induced Sleep Endoscopy
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.
Prof 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:
Nasal operations
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.
Septoplasty & Turbinate Reduction 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 Prof Vik Veer will choose the least invasive option to help patients breathe better.
Palatal operations
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.
Large Tonsils
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 less than 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 Prof 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 Prof 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.
There are also a number of nerve implants that can be used in sleep apnoea. Prof Vik Veer provides the Inspire and Genio Nyxoah devices for sleep apnoea.
Prof 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.
Laryngeal Obstruction
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.
Read more
This is an overview of the treatment of snoring and sleep apnoea. If you would like to know more, please use the links on this page to understand better what the treatment options for these conditions are.
If you would like more information or to book in a sleep study please contact Prof Vik Veer via his team of secretaries:
Press on the buttons below, if you want to narrow down your options.
Overview of Snoring & Sleep Apnoea
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