SNORING SURGERY

Snoring is defined as noisy or rough breathing during sleep, caused by vibration of loose tissue in the upper airway. Surgical treatments for snoring include several different techniques for removing tissue from the back of the patients throat, reshaping the nasal passages or jaw, or preventing the tongue from blocking the airway during sleep. The purpose of snoring surgery is to improve or eliminate the medical and social consequences of heavy snoring. Most insurance companies, however, regard surgical treatment of snoring as essentially a cosmetic procedure - which means that patients must cover its expenses themselves. The major exception is surgery to correct a deviated septum or other obstruction in the nose, on the grounds that nasal surgery generally improves the patients breathing during the day as well as at night.

Snoring as a medical problem
The connection between heavy snoring, breathing disorders, and other health problems is a relatively recent discovery. Obstructive sleep apnea (OSA) is a breathing disorder that was first identified in 1965. OSA is marked by brief stoppages in breathing during sleep resulting from partial blockage of the airway. A person with OSA may stop breathing temporarily as often as 20 - 30 times per hour. He or she usually snores or makes choking and gasping sounds between these episodes. The person is not refreshed by nighttime sleep and may suffer from morning headaches as well as daytime sleepiness. He or she may be misdiagnosed as suffering from clinical depression when the real problem is physical tiredness. In addition, the high levels of carbon dioxide that build up in the blood when a person is not breathing normally may eventually lead to high blood pressure, irregular heartbeat, heart attacks, and stroke. In children, heavy snoring appears to be a major risk factor for attentiondeficit/ hyperactivity disorder.

Although people with OSA snore, not everyone who snores has OSA. It is thought that OSA affects about 4% of middle-aged males and 2% of middle-aged females. Most adults who snore have what is called primary snoring, which means that the loud sounds produced in the upper airway during sleep are not interrupted by episodes of breathing cessation. Other terms for primary snoring are simple snoring, benign snoring, rhythmical snoring, continuous snoring, and socially unacceptable snoring (SUS). Although primary snoring is not associated with severe disorders to the same extent as OSA, it has been shown to have some negative consequences for health. A study published in April 2003 reported that habitual primary snoring is a risk factor for chronic daily headaches.

Snoring as a social problem
As the term SUS suggests, primary snoring can cause the same social problems for a person as does snoring associated with OSA. People who snore heavily often keep other family members, roommates, or even neighbors from getting a good nights sleep, which leads to considerable anger and resentment. Recent studies have found that the nonsnoring partner or roommate loses an average of an hours sleep each night. According to Dr. Kingman Strohl, head of a sleep disorders program in a Veterans Administration hospital, even the average volume of snoring (60 decibels or dB) is as loud as normal speech. Some people, however, snore around 80 - 82 dB, the sound level of a loud yell; a few have been recorded as reaching 90 dB, the sound level of loud rock music. One study found that 80% of people married to heavy snorers end up sleeping in separate rooms. A group of Swedish researchers reported that heavy snoring has the same level of negative effects on quality of life among adult males as high blood pressure, chronic obstructive pulmonary disease, heart disease, and similar chronic medical conditions.

Risk factors for snoring
Some people are at higher risk of developing problem snoring than others. Risk factors in addition to sex and age include:
• Genetic factors. The size and shape of the uvula, soft palate, tonsils, and other parts of the airway are largely determined by heredity.
• Family history of heavy snoring.
• Obesity. Severe overweight increases a persons risk of developing OSA.
• Lack of exercise. Physical activity helps to keep the muscles of the throat firm and strong as well as the larger muscles of the body.
• Heavy consumption of alcohol and tobacco.
• A history of frequent upper respiratory infections or allergies.
• Trauma to the nose, face, or throat.

Snoring is a commonplace problem in the general population in North America. About 12% of children over the age of five are reported to snore frequently and loudly. Among adults, 45% snore occasionally, while 25% snore almost every night. The problem usually grows worse as people age; 50% of people over age 65 are habitual snorers.

Problem snoring is worse among males than among females in all age brackets. With regard to racial and ethnic differences, a sleep research study published in 2003 reported that frequent snoring is more common (in the United States) among African American women, Hispanic women, and Hispanic men than their Caucasian counterparts, even after adjusting for weight and body mass index (BMI). African American, Native American, and Asian American males have the same rates of snoring as Caucasian males. Further research is needed to determine whether these differences are related to variations in the rates and types of health problems in these respective groups.

According to international researchers, heavy snoring appears to be more common in persons of Asian origin than in persons of Middle Eastern, European, or African origin.

Description
With the exception of UPPP, all of the surgical treatments for snoring described in this section are outpatient or office-based procedures.

Uvulopalatopharyngoplasty (UPPP)
Uvulopalatopharyngoplasty, or UPPP, is the oldest and most invasive surgical treatment for snoring. It was first performed in 1982 by a Japanese surgeon named S. Fujita. UPPP requires general anesthesia, one to two nights of inpatient care in a hospital, and a minimum of two weeks of recovery afterward. In a uvulopalatopharyngoplasty, the surgeon resects (removes) the patients tonsils, part of the soft palate, and the uvula. The procedure works by enlarging the airway and removing some of the soft tissue that vibrates when the patient snores. It is not effective in treating snoring caused by obstructions at the base of the tongue.

UPPP has several drawbacks in addition to its cost and lengthy recovery period. It can result in major complications, including severe bleeding due to removal of the tonsils as well as airway obstruction. In addition, the results may not be permanent; between 50% and 70% of patients who have been treated with UPPP report that short-term improvements in snoring do not last longer than a year.

Laser-assisted uvulopalatoplasty
Laser-assisted uvulopalatoplasty, or LAUP, is an outpatient surgical treatment for snoring in which a carbon dioxide laser is used to vaporize part of the uvula, a small triangular piece of tissue that hangs from the soft palate above the back of the tongue. The patient is seated upright in a comfortable chair in the doctors office. The doctor first sprays a local anesthetic - usually lidocaine - over the back of the patients throat, covering the patients soft palate, tonsils, and uvula. The second step is the injection of more anesthetic into the muscle tissue in the uvula. After waiting for the anesthetic to take effect, the surgeon uses a carbon dioxide laser to make two vertical incisions in the soft palate on either side of the uvula. A third incision is used to remove the tip of the uvula. The surgeon also usually removes part of the soft palate itself. The total procedure takes about half an hour.

LAUP is typically performed as a series of three to five separate treatments. Additional treatment sessions, if needed, are spaced four to eight weeks apart.

LAUP was developed in the late 1980s by Dr. Yves- Victor Kamami, a French surgeon whose first article on the technique was published in 1990. Kamami claimed a high rate of success for LAUP in treating a condition known as obstructive sleep apnea (OSA) as well as snoring. The procedure has become controversial because other surgeons found it less effective than the first reports indicated, and also because most patients suffer considerable pain for about two weeks after surgery. Although some surgeons report a success rate as high as 85% in treating snoring with LAUP, the effectiveness of the procedure is highly dependent on the surgeons experience and ability.

Somnoplasty
Somnoplasty, or radiofrequency volumetric tissue reduction (RFVTR) is a newer technique in which the surgeon uses a thin needle connected to a source of radiofrequency signals to shrink the tissues in the soft palate, throat, or tongue. It was approved by the Food and Drug Administration (FDA) for the treatment of snoring in 1997. The needle is inserted beneath the surface layer of cells and heated to a temperature between 158°F (70°C) and 176°F (80°C). The upper layer of cells is unaffected, but the heated tissue is destroyed and gradually reabsorbed by the body over the next four to six weeks. Somnoplasty stiffens the remaining layers of tissue as well as reducing the total volume of tissue. Some patients require a second treatment, but most find that their snoring is significantly improved after only one. The procedure takes about 30 minutes and is performed under local anesthesia.

Somnoplasty appears to have a higher success rate (about 85%) than LAUP and is considerably less painful. Most patients report two to three days of mild swelling after somnoplasty compared to two weeks of considerable discomfort for LAUP.

Tongue suspension procedure
The tongue suspension procedure, which is also known as the Repose? system, is a minimally invasive surgical treatment for snoring that stabilizes the base of the tongue during sleep, preventing it from falling backward and obstructing the airway. The Repose system was approved by the FDA in 1998. It consists of a titanium screw inserted into the lower jaw on the floor of the mouth and a suture passed through the base of the tongue that is then attached to the screw. The attachment holds the tongue forward during sleep.

The Repose system is done as an outpatient procedure under total anesthesia. It takes about 15 - 20 minutes to complete. The advantages of the tongue suspension procedure include the fact that it is reversible, since no incision is made; and that it can be combined with UPPP, LAUP, or a tonsillectomy. Its disadvantages include its relatively long healing time (one to two weeks) and the fact that it appears to be more effective in treating OSA than primary snoring. One team of American and Israeli researchers who conducted a multicenter trial concluded that the tongue suspension procedure requires further evaluation.

Injection snoreplasty
Injection snoreplasty was developed by a team of Army physicians at Walter Reed Hospital and introduced to other ear, nose and throat specialists at a professional conference in 2000. In injection snoreplasty, the surgeon gives the patient a local anesthetic and then injects a hardening agent known as sodium tetradecyl sulfate underneath the skin of the roof of the mouth just in front of the uvula. The chemical, which is also used in sclerotherapy, creates a blister that hardens into scar tissue. The scar tissue pulls the uvula forward, reducing the vibration or flutter that causes snoring.

Preliminary research indicates that injection snoreplasty is safe, has a higher rate of success than LAUP (about 92%), and is also less painful. Most patients need only one treatment, and can manage the discomfort the next day with a mild aspirin substitute and throat spray. The primary drawback of injection snoreplasty is that it treats only tissues in the area of the uvula. Snoring caused by tissue vibrations elsewhere in the throat requires another form of treatment. Injection snoreplasty costs about $500 per treatment.