Obstructive sleep apnoea: ENT assessment, CPAP and surgical options

NHS inform describes obstructive sleep apnoea as a relatively common condition where the walls of the throat relax and narrow or close during sleep. There are two types of interruption: apnoea, a total blockage of the airway for 10 seconds or more, and hypopnoea, a partial blockage that reduces airflow by more than 50% for 10 seconds or more. During an episode the lack of oxygen triggers the brain to pull you out of deep sleep, either to a lighter sleep or to wakefulness; the airway then reopens. You usually have no memory of this, so you may be unaware of the problem, but the repeated disruption leaves you very tired.

The NHS links sleep apnoea with obesity, having a large neck, getting older (although children and young adults can also get it), a family history, drinking alcohol, smoking, large tonsils or adenoids, sleeping on your back and chronic obstructive pulmonary disease. Large tonsils and adenoids are why ENT specialists are often involved.

At night the NHS lists breathing stopping and starting, gasping, snorting or choking noises, waking a lot and loud snoring. By day you may feel very tired, find it hard to concentrate, have mood swings or wake with a headache. NHS inform adds night sweats and waking often to pee. It can be hard to tell if you have it, so asking someone to watch you sleep helps.

See a GP if you have any of the main symptoms, particularly if you always feel very tired during the day. NHS inform suggests completing the Epworth Sleepiness Scale questionnaire before your appointment, which asks how likely you are to doze off in situations such as watching TV, sitting in a meeting or driving.

• Breathing pauses noticed by a partner.

• Gasping, snorting or choking noises.

• Loud snoring and restless sleep.

• Morning headaches and daytime sleepiness.

• Difficulty concentrating and mood changes.

The GP will usually ask about symptoms, may take your blood pressure and a blood sample to rule out other causes of tiredness such as an underactive thyroid or anaemia, and may refer you to a sleep specialist. NHS inform says the sleep specialists may measure height, weight and neck circumference, and arrange an overnight sleep study. The NHS says you may be given devices to check breathing and heartbeat, usually worn at home but sometimes in the clinic overnight. Home equipment can include a breathing sensor, heart rate sensors, chest bands, a finger oxygen sensor and a chin sensor, and the main in-centre test is polysomnography, which also monitors brain waves, muscle tone and more.

Severity is measured by how many breathing pauses occur per hour of sleep using the AHI. Treatment is most likely to benefit people with moderate or severe OSA and people who are very sleepy during the day, although it may also help some people with mild OSA, according to NHS inform.

Lifestyle changes such as losing weight, stopping smoking, cutting down alcohol and sleeping on your side may be enough for mild OSA, and the NHS also advises avoiding sleeping tablets unless recommended by a doctor because they can make it worse. Many people need a CPAP machine, which gently pumps air into a mask over the nose, or nose and mouth, to stop the airways getting too narrow. The NHS says it is available free on the NHS if you need it, can improve breathing and sleep, reduce tiredness and cut the risk of problems such as high blood pressure, and works best used every night. It may feel strange at first, so tell your doctor if you find it uncomfortable. NHS inform lists possible side effects as mask discomfort, nasal congestion, headaches and ear pain, wind and claustrophobia, and says telemonitoring may be used to check how well it is working.

A mandibular advancement device is a dental appliance like a gum shield sometimes used for mild OSA and as an option if CPAP is not right for you. NHS inform says they are not generally recommended for more severe OSA and may not always be available on the NHS, so you may need to pay privately, and that one should be made by a dentist with training in sleep apnoea. Guy's and St Thomas' says its dental sleep service uses such appliances for snoring and mild to moderate sleep apnoea.

NHS inform says surgery may be an option if OSA is thought to be the result of a physical problem that can be corrected surgically, for example enlarged tonsillar tissue, but for most people it is not appropriate and it may only be considered as a last resort if other treatments have not helped. The NHS lists surgery to help breathing, such as removing large tonsils, mouth and facial muscle exercises, and a device that sends small electrical signals to the nerve that controls the tongue (hypoglossal nerve stimulation) among other treatments.

An ENT assessment typically involves examining the nose, throat and tongue base, and sometimes a camera examination while awake. Surgeons should explain the realistic benefit, since results vary and OSA can persist after surgery. Weight loss and CPAP may still be needed.

GOV.UK says you must tell the DVLA if you have confirmed moderate or severe obstructive sleep apnoea syndrome with excessive sleepiness, or any other sleep condition that has caused excessive sleepiness for at least 3 months, including suspected or confirmed mild OSAS. You must not drive until you are free from excessive sleepiness, or your symptoms are under control and you are strictly following any necessary treatment. You can be fined up to £1,000 if you do not tell DVLA about a medical condition affecting your driving, and you may be prosecuted if involved in an accident. Ask your doctor if unsure.

The NHS lists untreated OSA risks including high blood pressure, a higher chance of stroke, type 2 diabetes, heart disease, depression or mood changes, serious accidents caused by tiredness and difficulty concentrating at work or school, plus strain on relationships.

The NHS route is GP, then a sleep clinic with a home or in-centre study, then CPAP or another treatment, with ENT involvement if tonsils or nasal obstruction need attention. Waiting times for sleep clinics vary across the UK.

Private sleep physicians, ENT surgeons and dentists offer faster testing and device fitting. CPAP bought privately should still be set up and followed up by a sleep service, and anyone with sleepiness should consider the DVLA rules while waiting.