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Excessive Daytime Sleepiness

This is one of the main symptoms of many sleep disorders. Initially, daytime sleepiness develops under passive conditions such as watching television and reading. However, as the disorders progress, sleepiness encroaches progressively into all daily activities and can become severely disabling and dangerous. Driving ability may become impaired with a high risk of road traffic accidents. Frequently associated with excessive daytime sleepiness are signs of intellectual impairment, memory loss, poor judgment and personality changes. Many times, the patient is unaware of excessive daytime sleepiness or intellectual deterioration till these are reversed with effective treatment.

Snoring

Snoring is the vibration of upper airway tissues during sleep. Snoring can disturb a bed partner’s sleep and often brings the patient to medical attention. In many patients, snoring has been present for many years. Loud, habitual snoring may occur with or without obstructive sleep apnoea which is a chronic, disabling disease with far reaching medical consequences.

Obstructive Sleep Apnoea Syndrome

A common, chronic and disabling disorder with repetitive, partial or complete obstruction of upper airways during sleep. This is a leading cause of excessive daytime sleepiness and may contribute to the development of high blood pressure, heart attacks and strokes in these patients. Almost all patients have years of loud, habitual snoring. Other symptoms include repetitive temporary breathing pauses during sleep, waking with a headache, impotence, waking gasping or with a smothering sensation and restless sleep with bedcovers often in disarray upon arising. Most patients have unrestful sleep, mental fogginess and disorientation.

Narcolepsy

This was the first primary sleep disorder to be described and characterized with reports dating back from over 100 years ago. This is a chronic, disabling condition with excessive daytime sleepiness and disturbed nighttime sleep. Sudden sleep episodes or sleep attacks may occur. Many patients also have cataplexy. These are sudden episodes of muscle weakness or paralysis triggered by emotions like laughter, anger, grief, fear, embarrassment and excitement. Patients may stagger, fall or slump during cataplectic attacks. Patients may also have sleep paralysis, which are brief episodes during onset of sleep or awakening when the patients may feel paralyzed and unable to move. Visual, dreamlike hallucinations may also occur either preceding sleep or preceding wakefulness.

Periodic Leg Movement Disorder and Restless Leg Syndrome

A common condition with disagreeable leg sensations, usually at rest and prior to sleep onset, causing an irresistible urge to move the legs. Repetitive, stereotyped movements of the legs may occur during sleep. These movements may cause repeated arousals from sleep and sleep disruption at night. This results in excessive daytime sleepiness.

Other major sleep disorders with EDS

These include abuse of central nervous system stimulant drugs, major depression, idiopathic hypersomnolence (daytime sleepiness without a known cause) and rare disorders like the Kliene-Levin syndrome.

Insomnia

Primary insomnia is a common disorder with inability to initiate or maintain sleep in the absence of other primary medical or psychiatric disorders. The causes of primary insomnia are mainly psychological and behavioral.

Full Overnight Polysomnography

Full overnight sleep study or polysomnography involves the recording of electrical activity of the brain, eyes and chin muscles. This allows sleep to be staged, quantitated and brief arousals from sleep to be recorded and identified. Recording the electrical activity of leg muscles helps in diagnosing periodic leg movement disorder. Standard respiratory measurements include recording overnight oxygen saturation by finger pulse oximetry, breathing movements of chest & abdomen, airflow from mouth & nose, and snoring. This is needed to diagnose obstructive sleep apnoea. Further channels to record additional data can be added.

Full overnight polysomnography or limited sleep study will always be required in all cases of snoring, suspected obstructive sleep apnoea or investigation of any sleep disorder.

Multiple Sleep Latency Test

Daytime sleepiness can be subjectively documented by the Stanford Sleepiness and Epworth Sleepiness scales. Multiple Sleep Latency Test (MSLT) is the most commonly used and experimentally validated objective test for quantifying daytime sleepiness. This is also used to document the presence of sleep onset dreaming sleep which is critical to establishing a diagnosis of narcolepsy.

The MSLT includes recording five 20 minute naps throughout the day at 2 hour intervals as per a strict protocol in a sleep inducing environment.

Other tests to objectively measure ability to stay awake are the Maintenance of Wakefulness Test and the OSLER Test.

CPAP Titration Study

Nasal Continuous Positive Airway Pressure (n-CPAP) is the treatment of choice for most patients with obstructive sleep apnoea. The pressure generator in the machine generates high airflow that is delivered to the patient by tubing. This maintains positive airway pressure in the upper airways and creates a pneumatic splint, hence preventing upper airway collapse during sleep.

The pressure required by an individual patient is usually determined by a sleep study. The pressure is gradually increased until the abnormalities in the recordings get abolished. This study is seldom required these days with the advent of newer, smart and variable pressure delivering CPAP units.

Upper Airway Imaging

Done for patients with obstructive sleep apnoea requiring surgical correction. This includes plain X-rays, cephalometry and upper airway CT or MRI scans.

Sleep Nasendoscopy

Videofluroscopy and nasendoscopy are the methods to directly visualize the dynamics of upper airways, sometimes during a sedative induced light sleep. These are used to delineate the exact site of collapse in the upper airways in patients with snoring and obstructive sleep apnoea requiring corrective palatal surgery or mandibular advancement splint.

CPAP

Continuous Positive Airway Pressure (CPAP) is the best and most successful mode of treatment for patients with obstructive sleep apnoea. It consists of an interface between the patient’s nose or nose & mouth, a valve to allow breathing out CO2, tubing to connect the interface to the pressure generator and the compressor itself, that generates high airflow to maintain positive airway pressure.

CPAP works by creating a pneumatic splint in the upper airway, preventing its collapse during sleep and increasing its size. CPAP decreases or eliminates excessive daytime sleepiness, improves quality of life and neurocognitive functions and may help in reducing the excessive vascular mortality of untreated obstructive sleep apnoea.

CPAP needs to be used with good compliance every night for over 5 hours each night. To improve and maintain good long term usage, patients need proper instruction and follow up on the use of the device. The mask fit must be proper and humidification optimal. Minor side effects can occur but most are treatable with simple measures.

Autotitrating CPAP units are available that adjust to provide the minimal pressure needed to eliminate obstructive events. These variable pressure delivering smart machines may be better than the conventional standard CPAP units.

Oral treatment

Stimulant drugs can be given to treat residual, persisting excessive daytime sleepiness in patients with obstructive sleep apnoea using CPAP. They are also used in Narcolepsy and idiopathic hypersomnolence. The commonest of these is Modafinil. Narcolepsy and periodic leg movement disorder are also treated with other drugs with good to variable effect.

Mandibular Advancement Splints

There are a variety of oral appliances to treat simple snoring and obstructive sleep apnoea. These devices are applied at night during sleep. They alter the upper airways in some way to increase upper airway size and improve patency. They can be fixed or adjustable. Most devices require dental impressions, bite registration and manufacture in a dental or maxillofacial laboratory.

Maxillo-mandibular advancement surgery

Maxillo-mandibular advancement has a limited application but can give high success rates in carefully selected patients with obstructive sleep apnoea. Both the upper and lower jaw is advanced as part of a stepwise or single stage program.

Diathermy/Laser Assisted Palatoplasty (DAUP/LAUP)

LAUP is recommended only for patients with simple snoring without obstructive sleep apnoea.

This procedure is a staged office-based procedure involving removal of excessive uvular mucosa and creation of transpalatal vertical troughs to effectively widen the retropalatal airway. LAUP has been used in the treatment of snoring for the last 20 years. It can be done either using a Laser or Diathermy machine, but the procedure is exactly the same.

It involves two cuts in the soft palate, on either side of the uvula, and trimming off a variable degree of the uvula itself. Sometimes the tonsils are removed at the same time (if large and contributing to the snoring).

The operation is carried out under general anaesthesia as a daycase. It may be done in combination with other procedures (eg. nasal surgery, if required). The success rate is 70-80% at three months. Weight gain, high alcohol intake or tissue laxity due to ageing may cause snoring to return. The post-operative period is very painful. It lasts approximately 10-14 days. Insurance companies do not pay for this type of surgery, but will usually pay a large share of it, if it is being done at the same time as another operation (eg. nasal surgery).

Restore Palatal Pillar Inplants

Pillar implant (PIT) is a simple, office-based procedure with minimal morbidity that was introduced in 2003 to treat snoring and mild/moderate obstructive sleep apnoea. Pillar implant in the soft palate stiffens it and is an effective treatment for snoring and obstructive sleep apnoea in selected patients and can be combined with adjunctive procedures to treat sleep apnoea.

These palatal implants, which are surgically implanted into to soft palate under local anaesthetic, are designed to stiffen the palate, and thereby reduce its vibration. It is this vibration which causes snoring. The implants are about the thickness of a match, but slightly shorter, (2mm x 18mm). They are made of Polyethylene tetrapthalate in a braided fibre format. This material is completely inert and causes no local tissue reaction. They are left in place permanently.

This involves injection of local anaesthetic into the area of the soft palate (as in dental injections) which numbs the area. The implants may now be placed using a pointed, needle-like introducer. No pain is felt at this stage at all. The procedure takes about 30mins altogether. Mild pain will be experienced for a day or two, but is easily controlled with simple painkillers, like Paracetamol or Nurofen. No time off work is needed and eating, drinking and speech are unaffected. An odd lump-like sensation may be present for a few days while the implants settle in. Only one treatment is required.

The success rate is 50-60% but long-term failure can occur, especially with excessive weight gain. The implants may rarely extrude and this may require removal and possibly replacement. Implants do not compromise the possibility of having any of the other available treatments for snoring or OSA.

Somnoplasty

Radiofrequency volumetric tissue reduction can be applied to the palate, tongue base and nasal septum. This may be less painful than LAUP. Somnoplasty is recommended primarily for patients with simple snoring without obstructive sleep apnoea.

There are two types of Somnoplasty-

• Celon® Radiofrequency Palatoplasty ("Somnoplasty")
• Coblation® Radiofrequency Palatoplasty

Celon® Radiofrequency Palatoplasty ("Somnoplasty")

This produces similar results to conventional palatal surgery but is far less painful. Initially developed by Somnus, (USA) and then refined by Celon, (Germany). In some clinics, this is referred to as "Somnoplasty", after the name of the company that developed it. Radiofrequency Palatoplasty (RF) is generally carried out under local anaesthesia and amounts to little more than a dental procedure.

The mouth is sprayed with local anaesthetic solution and then local anaesthetic is injected into the soft palate. This numbs the back of the throat completely, working the same as a dental injection does.

A probe is introduced into the palate which applies radiofrequency energy in linear "channels". This does not damage the sensitive mucus membrane covering the palate but produces scarring deep in the palatal muscle, which has the effect of tightening the muscle up because of its shrinking effect and thus reducing the loose vibration that causes snoring. Each application takes 10-20 seconds and there are usually six applications.

Usually, three or four treatments are required, as only a certain amount of radiofrequency may be applied at anyone sitting. After the second (or third) treatment, gradual improvement in the snoring starts. More than this is occasionally required, and may be carried out, if required. This treatment does not affect the voice or swallowing.

The whole procedure takes about 20-30 minutes. Fasting is not required, but patients should not drive home or use public transport alone on the way home. There is little discomfort and patients go straight back to work the next day and require little more than some pain killer tablets for a few days.

The success rate for this procedure (as a sole procedure) is 50-60% at three months. "Success" is defined as either complete abolition of snoring or a major reduction, such that the partner's sleep is no longer interrupted. Weight gain, excess alcohol intake and ageing can result in a recurrence of symptoms. This procedure does not preclude other forms of snoring treatment being undertaken.

This procedure is not funded by most insurance companies, and payment must therefore be personally made, even if you are insured.

Coblation® Radiofrequency Palatoplasty

This device & technique allows the surgeon more scope in correcting the precise palatal abnormalities which are responsible for snoring. This includes laxity of the soft palatal tissue, thickness of the palate, bulky tonsils.

The procedure consists of anaesthetising the palate with a combination of anaesthetic spray and injections, similar to that employed by dentists. Then, a radiofrequency hand-piece is used to incise the palate in two areas and to remove some of the Uvula, which hangs at the back of the throat. Once anaesthetised, the patient feels no pain, although awake. Then, "channels" of radiofrequency shrinkage are produced in the palate (and tonsils, if appropriate) to reduce the bulk of these structures. Sometimes, "webbing" must be removed from the lower edge of the palate too, as this holds it in a downward position, and may restrict improvement of the snoring.

The operation takes about 30 minutes to perform. It is not necessary to fast before the procedure but patients should not drive, or use public transport home.

Painkillers are prescribed and should be used regularly until the pain subsides. This operation is painfUl, although not as painful as a Laser I Diathermy Assisted Uvulo-Palatoplasty (LAUP/DAUP) and takes about a week to 10 days to recover. The voice is not affected, but swallowing is painful during the recovery period. An odd sensation in the throat may be present for some weeks afterwards, due to anatomic alteration. Time off work will be required, usually about 1 week. Snoring resolves over a 4-6 week period, as tissue shrinkage and scarring occur.

This is a "bigger" operation than the Celon Channelling treatment, but with a single treatment session, the success rate of this procedure is approximately 70%, (cf 50%-60% for Celon Palatoplasty or Restore Implants) although patients may begin snoring again in the event of weight gain, excess alcohol intake or in old age. This operation may be repeated, or combined with other anti-snoring treatments. "Success" is defined as total abolition of snoring or a marked reduction, such that the partner's sleep is no longer disturbed.

This treatment is not funded by insurance companies, and therefore payment must be made personally, in advance.

Prices Summary

The overall cost of Full Overnight Polysomnography is £1,504 payable to The Clementine Churchill Hospital

	Success Rate (%)	No. of treatments	Pain	Time off (days)	Cost
LAUP* (*G.A daycase)	+/-70	1	+++	10-14	£2,000
Coblation palatoplasty	60-70	1	++	7-10	£950
Celon ("Somnoplasty")	50-60	4-6	+	0	£950
Restore®Pillar Implants	+/- 50	1	+	0	£950
MAS	50-60	2-3 visits	0	0	£500
Maxillo-mandibular advancement surgery (G.A Inpatient)	Very high in selected patients	One stage surgery	-	Inpatient 3 days	£10,000 surgeon, anaesthetist, hospital charges & post-operative)