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Snoring is very common symptom affecting over 40% of adults. It is twice as common in men and the likelihood of snoring increases with age. Reassuringly in most cases it is not harmful to your health, although it may affect your or your partner’s quality of life. Up to 4% of people who snore however, may be suffering with a serious underlying condition called obstructive sleep apnoea (OSA).
What are the causes of Snoring?
Snoring results from noise that is generated from turbulent air flowing as air passes through the upper breathing passages: the nose, mouth, throat (including tonsils and soft palate), the tongue base and the voice box (larynx). There may be narrowing or floppiness of one or more of these areas and as air passes, vibratory motions cause the unpleasant sound. Careful evaluation to determine the exact location of the culprit area(s) is important when trying to alleviate the cause.
Here are some common reasons:
In the nasal passage blockage may be due to a fixed anatomical defect such as a deviated septum or a twist in the nasal framework; or there may be reversible swelling of the lining of the nasal cavity and sinuses. Swelling of soft tissue overlying bony protuberances in the nose called turbinates may be particularly troublesome. Rhinosinusitis (inflammation of the nasal and sinus lining) may result from a variety of causes including allergy, irritant chemicals, infection and in some cases may result in the development of obstructive nasal polyps. In children and some adults, especially in those with allergies, the adenoids may additionally be enlarged.
As we move down from the nose, an enlarged elongated soft palate and/ or uvula (the dangly bit resembling a punching bag) can be important noise generators.
In the throat, enlarged tonsils and a bulky tongue base are important causes of obstruction in both adults and children.
With age, muscle tone generally reduces, especially when asleep. The musculature surrounding the throat tends to collapse when breathing in, causing a further narrowing in this area. Fat deposits in the neck and in the tongue in overweight people will do the same.
Obstruction at the level of the oropharynx (the section that houses the tonsils and tongue base) and soft palate are major causes of snoring and obstructive sleep apnoea (see below). Although nasal blockage may indirectly worsen obstruction in this area too: open mouth breathing whilst asleep leads to the tongue being pushed back, particularly while lying on your back.
Some people may have unique facial framework anatomy such as a relatively small jaw bone or mid-facial skeleton. These features cause crowding in the oropharynx and a narrow nasal passage, predisposing them to airway obstruction.
Less commonly, masses or tumour growths in any of these areas or in the voice box may be a source of noisy breathing and must be excluded, particularly in people who have had a sudden onset of symptoms and have risk factors such as smoking or a family history of cancer. Your clinician may request a CT or MRI scan to help exclude this possibility.
Why we shouldn’t ignore snoring or other sleep related symptoms
Snoring and other sleep related symptoms may signify Obstructive Sleep Apnoea (OSA). In this situation, the obstruction is so severe that it temporarily stops or significantly reduces airflow for at least 10 seconds at a time. The frequency of occurrence may be potentially health and life threatening. The lack of oxygen to certain brain and respiratory centres will trigger an arousal (which may not reach consciousness) and send a burst of electrical activity to the muscles of the air passages and breathing apparatus causing a “gasp”. Your partner or other people may have alerted you to this behaviour when you sleep. Although an episode or two every hour of sleep can be normal, when it exceeds 5 times in the hour, you have OSA by clinical definition. In very severe cases these obstructive episodes can occur more than once a minute and may be hazardous to health.
What are the other symptoms of OSA?
Weight gain is strongly correlated to OSA, but severe OSA can and does occur in patients of lighter build, so they should not be discounted.
Stopping breathing and waking up gasping for breath as described above is a common anxiety provoking symptom; sleep is often unrefreshed and you may wake up with a headache. Symptoms are commonly worse when lying on the back. This often leads to daytime tiredness and impairment of your ability to think and work.
There may be additional symptoms not obviously related to OSA, such night sweats, the sensation of a racing heart and the need to go to the toilet to pass urine multiple times. A reduced libido and sexual function have also been linked strongly with OSA.
Left untreated, OSA has been correlated with the acquisition of serious chronic conditions like diabetes, heart disease, high blood pressure and stroke.
How is OSA diagnosed?
As part of history taking you will be requested to fill out one or more validated questionnaires (including an Epworth Sleep Questionnaire). These will help quantify the severity of your symptoms. Jaw size, mouth opening and the position of the tongue and tonsils will be quantified. An internal examination of the face, jaw and upper airway will be performed with the aid of a thin flexible high definition camera unit called a nasendoscope. It will be passed through the nose to examine the nasal cavity, the adenoid area, the back of the throat, tongue base and voice box components.
The sleep study
It is important to determine whether you have simple (non-health threatening) snoring or OSA. Furthermore, a small percentage of patients may suffer from neurological conditions that cause them to stop breathing in the absence of obstruction. It is important to distinguish these different possibilities as their management differs. Therefore, your doctor will likely arrange for you to have a sleep study.
There are essentially two types of sleep study: the simplest involves taking a machine home and attaching it to your finger while you are asleep. More sophisticated home ambulatory machines may measure nasal airflow and chest movement. In most cases this suffices to make a diagnosis, however for some people further information about your body’s physiology may be required and a more detailed in-patient sleep study will be required.
None of these sleep studies are invasive and both types are well tolerated.
Drug induced sedation endoscopy (DISE)
Whilst awake it is almost impossible to accurately determine the section of airway anatomy responsible for the snoring or obstruction. When you are awake, the resting tone of the surrounding musculature tends to splint open and the tongue will be held forward.
If you or your clinician are contemplating surgical management then it is our practice that you have a prior endoscopic assessment of the airway under sedation and anaesthesia. A general anaesthetic agent will be administered to induce sleep and the onset of snoring. An endoscope will be gently passed through the nose to examine the upper airway to determine which anatomical area(s) may be responsible for the noise and obstruction. At the same time, we will also determine the effect of gently advancing the jaw on the airway volume. A more formal transoral (through the mouth) endoscopic examination may additionally be performed under the same general anaesthetic, to determine the ease of access for potential surgical management. The sedation endoscopy is usually a day surgical procedure and is very safe.
The whole procedure will be video recorded and be used in a discussion with you about providing you with an individually tailored surgical plan.
What treatment is available?
All patients with sleep disordered breathing will benefit from giving up or cutting back on muscle relaxing or inflammatory agents like alcohol and smoking. If overweight, weight loss is the single most important thing you can do to help all sleep related breathing disorders. It will also improve the outcome of any surgical procedures we recommend.
Although not likely to be curative in isolation, certain throat and tongue muscle exercises (myofunctional therapy) may improve some people’s symptoms. Sleeping positional manoeuvres such as sleeping on your side and front may also help.
Medical management and devices
If you are found to have nasal lining inflammation, then snoring may improve following treatment with a topical nasal steroid and/ or short-term decongestant. In selected patients, external nasal valve opening strips may also be useful.
Mandibular advancement splint
If your DISE study demonstrated a reduction of snoring or an enhanced opening of the airway when the lower jaw was advanced, a mandibular advancement splint may be of benefit. There are numerous devices available commercially, but the best and most comfortable device is one that has been custom built to fit your jaw and dental anatomy. These are built to your specification by dedicated orthodontic specialists. You will need to have healthy teeth to be able to hold this device comfortably in your mouth whilst you are asleep.
CPAP (continuous positive airways pressure)
A CPAP device is essentially a machine that delivers pressurised air through a nasal or face mask to help a splint open the upper airway whilst you are asleep. The mask needs to be tight fitting to prevent air escape. It is highly effective and is currently the treatment of choice for moderate to severe OSA. All new patients diagnosed with OSA will initially be referred to a respiratory consultant with a specialist interest in sleep medicine for consideration of CPAP.
For CPAP to be effective however, it needs to be used daily for at least 7 hours a night for a prolonged period of time. This can be problematic for many, with air leak, ill-fitting irritation to the skin, rhinitis, air swallowing and claustrophobia sited as some of the reasons for discontinued use. In addition, for a small percentage of patients, CPAP is unable to be delivered at high enough pressures to be effective. These patients have traditionally been very difficult to manage from both medical and surgical perspectives.
We have a special interest and unique high-volume experience in successfully managing such patients (see below).
Surgery for OSA
The surgical strategy we adopt will always involve a preliminary DISE procedure. Additional information on the size and nature of any obstructive tissue may be gained from performing an MRI or CT of the neck. This will identify the culprit areas that need to be addressed and demonstrate individual variation in blood supply to them to help us minimise complications. The surgical strategy offered to you will also be influenced by whether you have moderate to severe OSA.
If you have an obvious nasal deformity such as a deviated nasal septum or inferior turbinate enlargement you may be offered surgery to correct these. This often involves a septoplasty procedure to straighten the septum and/ or reduction of inferior turbinate tissue. The latter can be done in different ways ranging from laser vaporisation to endoscope mediated turbinate bone removal. If the adenoids are enlarged, they should also be removed at the same time.
As sleep does not affect nasal anatomy in the same way as that of the throat and tongue musculature, such defects can be diagnosed in the clinic and could subsequently be managed at the same time as DISE.
Other targets identified on DISE will be discussed with you at a later date, in concert with the video recording of your airway anatomy. A second stage operation may then be offered, tailored to your unique anatomical problem(s). Examples of procedures you may be offered include: a palate shortening and/ or stiffening procedure (for example laser palatoplasty, barbed expansion sphincter-pharyngoplasty), tonsillectomy and targeted surgery to the tongue base.
Very rarely a blockage may exist at the level of the voice box entrance and a procedure such as epiglottis reduction may be helpful.
These procedures require special expertise to prevent serious complications. It is important to reiterate that the nature and type of treatment offered will be strictly determined by the pattern of obstruction seen on DISE.
Transoral robotic surgery to the base of tongue
For patients with OSA, surgery plays one of two roles.
1. Relieving obstruction of the nasal and throat airway may improve the delivery of pressurised air, thereby improving the efficacy of and your compliance with CPAP. Indeed the severity of your OSA may also improve.
2. For some carefully selected patients, surgery may actually reverse the need to use CPAP altogether.
We have found transoral (via the mouth) robotic surgery to be extremely useful in this patient group. At OneWelbeck, our group has one of the largest UK-wide experiences of managing OSA patients on CPAP with transoral robotic surgery to deal with difficult areas such as the tongue base. We would usually contemplate this procedure on patients with moderate to severe OSA who are struggling with their CPAP machine.
A distinct advantage of a robotic assisted transoral operation is that it affords a hugely magnified and widened view of the contents of the throat, back of tongue and voice box area. Views that are not possible with standard transoral equipment or indeed in our opinion any other minimal access equipment available today. The articulated robotic arms are more versatile than a human and this combination of unparalleled vision and manoeuvrability aids the precise removal of obstructing tissue with maximal sparing of healthy tissues and important nerves and vessels. All this without the need for external neck scars or division of the facial skeleton for access.
Our latest audit of patients with OSA on CPAP, who were treated with transoral robotic tongue base surgery as part of their individualised surgical strategy, has demonstrated tremendous early success, with 90% of patients not requiring their CPAP machine after recovering from their operation.
As a team, we are constantly looking at ways to improve the quality of care to our patients and to be able to offer our patients the best and most efficacious of modern techniques and innovations. An example of this is our successful use of transoral robotic surgery described above.
There will however be a proportion of patients who may not be suitable for such treatment. There may be alternative, more invasive treatments that we could consider, but other innovations have and are being developed that might prove useful. One such is hypoglossal nerve stimulation, which is essentially a pacemaker, electrically attached to nerve branches that make the tongue move forward. When turned on, the electric signals to the tongue are synchronised with the breathing muscles essentially protruding it as you breath in. It has demonstrated benefit in carefully selected patients with OSA in Europe and America but as yet it is not available in the UK. We are anticipating being one the first group of surgeons to use this technology.
Get in touch
To speak with a specialist about Snoring and Obstructive Sleep Disorders, contact our team today.
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