Sleep disorder usually refers to snoring or obstructive sleep apnea (OSA). The common reason for both these condition is partial or complete closure of your upper airway during sleep.

Snoring is the sound generated by the vibration of the structures at the back of your throat. Simple snoring is not associated with excessive daytime sleepiness or difficulty in sleeping at night.

Obstructive sleep apnoea (OSA) is a condition where your breathing stops for short spells when you are asleep. The word apnoea means without breath - that is, the breathing stops. In OSAan obstruction to the flow of air down your airway causes your breathing to stop. This obstruction to the airflow most commonly occurs in the throat. However, it is not uncommon for breathing to stop for few seconds in healthy people during sleep. Only when apnoea occurs more than 5 times every hour, each time for more than 10 seconds, that it becomes a health problem and we call it OSA. During these episodes there is at least 3% to 4% fall in your blood oxygen. You wake up briefly after each episode of stopped breathing to start breathing again. You do not usually remember the times you briefly wake up, but you have a disturbed night's sleep. This is associated with excessive daytime sleepiness, waking with gasping, choking, or breath holding. Snoring between these episodes is a frequent complaint of bed partners and is often the reason that prompts these patients to seek medical attention.

Follow this link (in English) to watch a video on sleep apnea

http://www.sleepapnea.org/learn/more-on-sleep-apnea.html

When we sleep, all the muscles in our body including the throat muscles relax and become floppy. In most people, this does not block breathing. If you have OSA, the throat muscles become so relaxed and floppy during sleep that they cause a narrowing or even a complete blockage of the airway.
When your airway is narrowed it restricts flow of air, at first this causes snoring. If there is a complete blockage then your breathing actually stops (apnoea). Your blood oxygen level then goes down and your brain detects this. Your brain then tells you to wake up and you make an extra effort to breathe. Then, you start to breathe again with a few deep breaths. You will normally go back off to sleep again quickly and will not even be aware that you have woken up. Your bed partner will notice that you stop breathing for a short time, and then make a loud snore and a snort, and then get straight back off to sleep. For the diagnosis of OSA, you need to have at least five episodes of apnoea per hour of sleep. However, there are different levels of severity of OSA (mild, moderate or severe). People with severe OSA can have hundreds of episodes of apnoea each night. OSA is classified as:

• Mild OSA - between 5-14 episodes an hour.

• Moderate OSA - between 15-30 episodes an hour.

• Severe OSA - more than 30 episodes an hour.

Snoring or OSA can occur at any age, including in children. However whereas snoring is very common, few of us have OSA.Studies in the western world show that snoring affects at least 40% of men and 20% of women whereas OSA is seen in 5% of men and 3% of women.Remember - very few people who snore have OSA while almost all OSA patients snore!

Factors that increase the risk of developing OSA, or can make it worse, include the following. They all increase the tendency of the narrowing in the throat at night to be worse than normal.

  • Overweight (BMI above 25) and obesity (BMI above 30)
  • Thick neck (usually if the Collar size is more than 17 inches in males or 16 inches in females) because the extra fat in the neck can squash the airway.
  • Drinking alcohol before sleep as itcauses excessive relaxation of the muscles and also makes the brain less responsive to an apnoea episode. This may lead to more severe apnoea episodes in people who may otherwise have mild OSA.
  • Enlarged tonsils and /or adenoids – This is the number 1 cause in children
  • Taking sleeping tablets or tranquilizers
  • Sleeping on your back rather than on your front or side
  • Having a small or a jaw that is set back further than normal
  • Smoking – by causing an inflamed swollen airway

Even if you have OSA, you may not be aware of it as you will not usually remember the waking times at night. It is often your sleeping partner (or the parent if it is a child) that is concerned about the loud snoring and the recurring episodes of apnoea that they have noticed. However, you may be aware of the following problems -

• Daytime sleepiness and being tired

• Poor concentration and mental functioning

• Not feeling refreshed on waking

• Morning headaches

• Being irritable during the day

• Pass urine frequently during the night

• Night sweats

• Reduced sex drive

In children significant OSA has been linked to poor performance in studies and sports and some studies have shown a weak link to reduced overall intellectual development.

OSA can be a serious health problem in adults as studies have shown that OSA without treatment can either lead to or worsen the following medical conditions

Hypertension

Heart attacks

Stroke

Type 2 Diabetes Mellitus

OSA is diagnosed based on your complaints, the findings on your physical examination and results of tests

Your symptoms

If you have daytime tiredness, sometimes a questionnaire is used to measure to estimate the level of sleepiness that you feel during the daytime. A score above 10indicates that you may have a sleeping disorder such as OSA. However, it is important to realize that many people with high score will NOT have sleep apnoea and not everyone with sleep apnoea will have a high score. Therefore, it is vital that you do not consider the score on ESS as confirmatory as this has to be combined with your complete medical assessment and other investigations.

Tests to confirm OSA

If you have symptoms mentioned above that suggest OSA, or a high score on the Epworth Sleepiness Scale, we may recommend certain tests. There are many types of test that can be done whilst you sleep, the most common ones are mentioned below

• Pulse Oximeter – Monitors the oxygen level in your blood by a probe clipped on to your finger.

• Polysomnography – This is the best but also least available and most costly test that monitors various aspects of your sleep, such as the airflow through your nose, your chest movement, the electrical activity of your brain, snoring volume, blood oxygen saturation and a video of your sleep.You may be asked to spend a night in the sleep lab for these tests to be done. The information gained from the tests can help us to firmly diagnose or rule out OSA.

• We may also suggest other tests to exclude other causes of your sleepiness. For example, a blood test can check for an underactive thyroid gland or overactive pituitary gland.

Clinical Examination

If you are bothered by significant snoring or have had tests showing OSA, physical examination is carried out to see the site that is obstructing your airway. This includes examination of your nose, throat and voice box, most commonly by a bendy camera that is passed through one of your nostrils (flexible naso-laryngoscope). This is usually done in the clinic while you are awake. However, if surgery is being contemplated, we may do this under a short anesthesia to mimic your sleep.

Before having any operation, it is advisable to consider the following treatment options as the majority of OSA patients will benefit/get cured by these.

In adults, generally surgery should be the last option!

1. Changes to your life style and habits

This is the first step and you may find significant benefit from making the following changes –

• Losing some weight if you are overweight or obese

• Not drinking alcohol for 4-6 hours before going to bed

• Not using sedative drugs

• Stopping smoking if you are a smoker

• Sleeping on your side

• Keeping props under the head end of your bed to elevate it and by using extra pillows

2. Continuous positive airway pressure (CPAP)

This is the most effective non-surgical treatment for OSA and should be tried before considering an operation if the changes mentioned above do not work or are not possible. This involves wearing a mask when you sleep that is connected to an electrical machine that pumps room air into your nose at a slight pressure. The air pressure keeps the throat open when you are breathing at night and so prevents the blockage of airflow. If CPAP works, (as it does in most cases) thensnoring is reduced or stopped and there is animmediate improvement in sleep. Lifelong treatment is needed. Sometimes you can have problems with throat irritation or dryness or bleeding inside you nose, which can be treated by newer CPAP machines that tend to have a humidifier fitted.Some people find the device cumbersome to wear at night. Due to these problems, around 40% to 50% OSA patients fail to use CPAP for long.

3. Mandibular advancement devices

These are devices that you can wear inside your mouth when you sleep. They work by pulling the mandible forward a little so that your throat may not narrow as much in the night. These devices look a bit like gum shields that sports-people wear. To get the best results, you should get one properly fitted by a dentist that is tailor made to the shape of your teeth and gum.

Surgery is the last resort in adults.The aim of operation is to increase the airflow into your airway. The correct surgery for you would depend upon where your obstruction is and to what degree. As mentioned above, an accurate evaluation is critical to decide this so that the correct surgery is carried out for you

1. Tonsillectomy +/- Adenoidectomy

This is most commonly done in children with significant snoring or OSAS as a relative large size of these structures is the commonest cause in that age group. Occasionally, adults have enlarged tonsils and will benefit from their removal.

2. Nose Surgery

Its rare for your nose to be the cause of obstruction. If they are, operation to straighten the nose, the septum inside or to widen the inside can be done. This can also be very useful if blockage in your nose is making it difficult for you to use the CPAP machine.

3. Uvulopalatopharyngoplasty (UVPP) -

is a procedure used to remove excess tissue in the throat to widen and allow air to move through the throat more easily when you breathe, reducing snoring. The tissues removed may include:

  • The small finger-shaped piece of tissue (uvula) that hangs down from the back of the roof of the mouth into the throat.
  • Part of the roof of the mouth ( Soft Palate)
  • Enlarged throat tissue, tonsils and adenoids

What To Expect After UVPP

It takes about 3 weeks to recover from surgery. It can be quite painful and it may be very difficult to swallow during this time. In addition it is usual to notice small amount in blood in your throat or sputum while the wound heals itself. During the healing period, you may find yourself choking, especially when you drink thin fluid. You are likely to notice improvement at about 3-4 weeks after the operation.

How successful is UVPP ?

The success of UVPP is dependent on proper patient selection based on good examination by experienced clinician. If used in inappropriate cases the long term success rate is less than 30% to 40%. However, in carefully selected patients it can cure snoring in 80% of those who have had this surgery.

What are the risks / potential complications of UVPP?

Like any other surgery, UVPP has some possible known complications that are mentioned below

  • Swelling, infection, and bleeding
  • Pain and trouble swallowing
  • Drainage of secretions into the nose and a nasal quality to the voice. Speech may be affected by this surgery
  • Narrowing of the airway in the nose and throat
  • Recurrence of snoring or OSA after a year or two

The last three complications mentioned above are relatively common with old-fashioned UVPP. However a new technique was developed in USA that has tremendously reduced these risks. I practice this modified technique of UVPP (Z-Palatoplasty) and I have found a very high satisfaction and success rate in my patients.

4. Robotic-Assisted Tongue base Surgery

Robotic surgeries for surgical treatment of sleep apnoea are the latest innovation that have shown very high long-term success rate in carefully selected patients.

You can follow this link to learn more about robotic surgery in general.

Robotic surgery for sleep apnea is primarily used if you cannot tolerate the CPAP device and the main area of airway narrowing is at the back of your tongue and/or the upper end of your voice box. Therefore a careful endoscopy by an experienced clinician is crucial to identify the precise location of airway collapse or obstruction. This diagnostic procedure helpsdetermine the type and extent of surgery to perform. For example, we may need to remove portions of the back of the tongue, the soft palate or other structures at various levels of the upper airway. Based on the examination finding we may have to combine UVPP with Robotic surgery. In most cases with sleep apnea, the obstruction is maximum at the level of tongue and therefore operation to reduce it, is very effective.

This individualized approach for each patient is critically important in improving surgical outcomes and successfully treating obstructive sleep apnea. In a large number of patients, the procedure may significantly reduce the frequency of airway blockages during sleep and may completely eliminate the need to use a CPAP device during sleep. In some cases, the surgery may not be able to reduce the frequency of airway blockage sufficiently to eliminate the use of a CPAP device. However, because the airway is now larger, you may be able to tolerate the CPAP device better after surgery. By using the da Vinci Robotic Surgical System we are able to work with greater accuracy and precision in the confined spaces of the upper airway. The robotic device provides a clear, high-definition view of the surgical field and enables us to perform delicate procedures with improved precision and enhanced surgical dexterity.

Advantages of surgery performed with the da Vinci Si Surgical System often include:

  • Greater precision during delicate surgical procedures
  • Earlier discharge from the hospital
  • Less pain, blood loss and scarring
  • Quicker return to normal activities
  • Fewer infections and post-surgical complications

What To Expect After Robotic surgery for sleep apnoea?

Operation on the back of tongue causes swelling that can obstruct your airway completely. It takes around 12-24 hours for this swelling to reduce. Therefore, for this duration, you will breath through a tube going through your mouth and you will need to stay in ICU. You are likely to remain in hospital for 2-3 days after operation. It takes about 3 weeks to recover from surgery. It can be quite painful and it may be very difficult to swallow during this time. In addition it is usual to notice small amount in blood in your throat or sputum while the wound heals itself. During the healing period, you may find yourself choking, especially when you drink thin fluid. You are likely to notice improvement at about 3-4 weeks after the operation.

What are the risks / potential complications of robotic surgery for sleep apnoea?

Though robotic surgery is very safe, like any other operation it has some possible complications that are mentioned below –

  • Bleeding – This is the commonest complication and we may need to operate again to control it.
  • Pain and trouble swallowing
  • Drainage of secretions into the nose and a nasal quality to the voice. Speech may be affected by this surgery
  • Narrowing of the airway in the nose and throat
  • Recurrence of snoring or OSA after a year or two

5. Procedures for the roof of your mouth (Palate)

In some patients, surgery for roof of mouth is required as that is the main site of obstruction. The choice of procedure depends on the degree of obstruction related to how much excess tissue you have. Naturally, precise diagnosis is crucial for successful treatment. By themselves, they are more useful for snoring but can be useful if done with one of the procedure mentioned above if you have sleep apnoea.

The suitable procedures vary in their range of resection and include

  • Uvulectomy –This is removal of the small finger-shaped piece of tissue (uvula) that hangs down from the back of the roof of the mouth into the throat.
  • Injection Palatoplasty - With Injection Palatoplasty, the soft tissue in the roof of the mouth is injected with a suitable material to create stiffening of the soft palate. Snoring is reduced by minimising the flutter or vibration of the soft palate.The very long-term results of this are not known at this stage, as Injection Palatoplasty has been under investigation for only the last two years. Repeat injections may be helpful if a useful result has not occurred within the first couple of months of the procedure or possibly one to two years after the initial injection should the initial benefits wear off and snoring symptoms recur.
  • Palatal advancement refers to surgery which cuts away the back end of the hard part of mouth roof so that the soft part can be pulled forward to create more space at the back of your throat.

Many surgeons offer snoring and / or sleep apnoea surgery across India. Your chance of success and having complication from operation is heavily influenced by the expertise and skills of your surgeon. When treating snoring and sleep apnoea it is critical to choose the correct procedure amongst the range mentioned above. This relies on the surgeons experience in deciding in which areas your airway is narrow and how much tissue needs to be removed.

By choosing me as your surgeon, you will be choosing someone who has extensive experience in the highest quality snoring and sleep apnoea surgery in the best centers of UK, USA and Australia. I can ensure good quality operation with minimal risk of complications. The difference is in quality. You have one body and it deserves the very best.

One of the main reasons for my decision to leave my consultant position in Britain and move to USA was to get trained in the use of robotic surgery. I have spent considerable time and effort gaining this skill and experience at one of the most reputed hospital in USA. By choosing me as your surgeon; you will be placing your care in the hands one of the most experienced and well-trained robotic surgeon in India.

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