Patients who snore tend to fall into 2 categories, those with some degree of obstructive sleep apnoea and those without obstructive sleep apnoea. Treatment for each type of problem is different. Below are outlined the diagnostic pathway which each type of patient will follow and the management for the type of snoring diagnosed.
YOU SHOULD BE AWARE THAT MOST INSURERS WILL NOT COVER THE COST OF OUT PATIENT VISITS, DIAGNOSTIC TESTING OR TREATMENT OF PATIENTS WITH EITHER OBSTRUCTIVE SLEEP APNOEA OR SIMPLE SNORING.
When you are seen in clinic you will answer a questionnaire known as the Epworth Sleepiness Score. Patient’s who score 10 or more on this questionnaire are likely to have some degree of sleep apnoea contributing to their problem. These patients would be referred for a sleep study to determine whether they have sleep apnoea or not. This is non-invasive and the result is read by an expert and a report sent to us.
If the result shows no obstructive sleep apnoea (or very little) discussion is had with the patient as to whether or not they are deemed suitable for either a mandibular advancement splint or Celon palatoplasty, or laser palatoplasty.
Sleep nasendoscopy is advised to determine where the snoring originates. This helps decide appropriate treatments. Following the sleep nasendoscopy, whilst under anaesthesia, the patient can undergo treatment to the palate of whatever type, and also radiofrequency to the base of the tongue. Those patients who chose not to have sleep nasendoscopy can make immediate arrangements for treatment. Other treatment for the palate can be laser assisted uvulopalatoplasty (LAUP). This is much more painful than Celon palatoplasty.
Patients who have moderate or severe obstructive sleep apnoea are not usually suitable for either mandibular advancement splint or Celon palatoplasty or LAUP and are referred on for continuous positive airway pressure therapy (CPAP). This consists of mask applied to the nose whilst you are asleep which forces air into the airway keeping the passages open and preventing episodes of apnoea (periods when your body stops breathing for longer than is normal) from occurring.
This is an attempt to determine where the snoring may be coming from. It is performed with the patient asleep, using sedation (midazolam). Whilst the patient is snoring a very thin flexible fibreoptic camera is passed down the nose to assess the level of snoring. It is graded using the Pringle/Croft scale
- Simple palatal snoring
- Single level palatal obstruction
- Multi segmental obstruction / inspiratory tongue base
- Sustained multisegmental / inspiratory and expiratory
- Tongue base obstruction only
This is quite operator dependant and the evidence supporting it’s use is variable. However if a general anaesthetic is to be given for example with nasal surgery, then the extra information gained from sleep nasendoscopy may well be useful in tailoring patient specific snoring surgery.
It is usually necessary for the treatment to be repeated 6 weeks after the first treatment. This provides the best result with this method.
Celon palatoplasty can be undertaken as an outpatient procedure under local anaesthesia. It results in minimal pain and takes less than ten minutes. It is gentle and efficient. The patient can leave the clinic immediately after the procedure and can return to work in one to two days. Radiofrequency energy heats the tissue to above 60°C causes electro-coagulation of the surrounding tissue (as shown in the diagram) followed by healing with scarring. This causes stiffening of the palate, and reduction in the bulk of the base of the tongue. The current is bipolar as so it is suitable even for patients with cardiac pacemakers. 10 points of radiofrequency are applied to the palate in a fishbone pattern. 10 Units of energy are applied to each site. The palate is treated with the probe in the directions shown in the diagram.
If the uvula is particularly long, it can also be shortened with the celon radiofrequency device. The abstract from a scientific study from London can be seen by clicking here. This has shown the efficacy of this procedure.
There is minimal pain following this procedure, and is well tolerated under local anaesthesia. There may be some minor swelling of the palate and some minor discomfort, but this lasts only a couple of days after the procedure. It is not necessary to use antibiotics following this procedure. Risks with this procedure are minimal pain and sometimes palatal ulceration. Ulceration occurs if the radiofrequency probe is applied too close to the surface of the palate. It usually heals however with no long term problems. Also this does not always work for snoring.
The operation does have to be repeated to get maximal benefit.
The base of tongue may also be treated to reduce bulk in this area, and therefore further help with snoring. This is performed under general anaesthesia. About 6 points of radiofrequency are applied to the base of the tongue, at and adjacent to the midline. The energy setting is again 10.
This is another surgical method for reshaping, shortening and stiffening the soft palate. This stops it from vibrating as much, and therefore also reduces snoring. It is more painful than celon radiofrequency, and also removes some of the tissue of the palate. If the palate is too long however, this certainly can be helpful. Again it can be performed under local anaesthesia, although it is my preference to perform this under general anaesthesia. It can be combined with sleep nasendoscopy. This is quite painful, and you would need to be off work for two weeks.
These work by bringing the tongue forward at night, thereby reducing the vibrations (and snoring) generated at the back of the tongue when sleeping. There are many different types. Some more easily tolerated than others. You may wish to discuss this therapy with your dentist as it does involve long term use of a mouth guard worn at night. Alternatively, Mr Simon Ash provides mandibular advancement splints which are very light and easy to tolerate. Information on these is available via the Somnowell website www.somnowell.com.
CPAP is the ‘gold standard’ treatment for Obstructive sleep apnoea. It involves wearing a nasal mask at night whilst sleeping. Through this flows continuous low pressure air. This keeps the airways open at night and prevents snoring. More importantly it prevents and treats the sleep deprivation that goes along with severe obstructive sleep apnoea. For this reason the patients general well being is significantly improved, as is the patients overall health and quality of life. Therefore the patients are often compliant with what may seem an uncomfortable therapy. In fact most patients are very tolerant of the nasal mask, and delighted to feel as well as they do on this treatment. CPAP is provided by a respiratory physician.