SNORING SURGERY 2

The most important task in diagnosing a patient’s snoring is to distinguish between primary snoring and obstructive sleep apnea. The reason for care in the diagnosis is that surgical treatment without the recommended tests for OSA can complicate later diagnosis of the disorder.

The sounds made when a person snores have a number of different physical causes. Snoring noises may result from one or more of the following:
• An unusually long soft palate and uvula. These structures narrow the airway between the nose and the throat. They act like noisy flutter valves when the person breathes in and out during sleep.
• Too much tissue in the throat. Large tonsils and adenoids can cause snoring, which is one reason why tonsillectomies are sometimes recommended to treat heavy snoring in children.
• Nasal congestion. When a person’s nose is stuffy, their attempts to breathe create a partial vacuum in the throat that pulls the softer tissues of the throat together. This suction can also produce a snoring noise. Nasal congestion helps to explain why some people snore only when they have a cold or during pollen season.
• Anatomical deformations of the nose. People who have had their noses or cheekbones fractured or who have a deviated septum are more likely to snore, because their nasal passages develop a twisted or crooked shape and vibrate as air passes through them.
• Sleeping position. People are more likely to snore when they are lying on the back because the force of gravity draws the tongue and soft tissues in the throat backward and downward, blocking the airway.
• Obesity. Obesity adds to the weight of the tissues in the neck, which can cause partial blockage of the airway during sleep.
• Use of alcohol, sleeping medications, or tranquilizers. These substances relax the throat muscles, which may become soft or limp enough to partially close the airway.

Because snoring may be related to lifestyle factors, upper respiratory infections, seasonal allergies, and sleeping habits as well as the anatomy of the person’s airway, a complete medical history is the first step in determining suitable treatments. In some cases the patient may have been referred by his or her dentist on the basis of findings during a dental procedure. A primary care doctor can take a history and perform a basic examination of the patient’s nose and throat. In addition, the primary care doctor may give the patient one or more short questionnaires to evaluate the severity of daytime sleepiness and other problems related to snoring. The test most commonly used is the Epworth Sleepiness Scale (ESS), which was developed by an Australian physician, Dr. Murray Johns, in 1991. The ESS lists eight situations (reading, watching TV, etc.) and asks the patient to rate his or her chances of dozing off in each situation on a four-point scale (0–3, with 3 representing a high chance of falling asleep). A score of 6 or lower indicates that the person is getting enough sleep; a score higher than 9 is a danger sign. The ESS is often used to measure the effectiveness of various treatments for snoring as well as to evaluate patients prior to surgery.

The next stage in the differential diagnosis of snoring problems is a detailed examination of the patient’s airway by an otolaryngologist, who is a physician who specializes in diagnosing and treating disorders involving the nose and throat. The American Sleep Apnea Association (ASAA) maintains that no one should consider surgery for snoring until their airway has been examined by a specialist. The otolaryngologist will be able to determine whether the size and shape of the patient’s uvula, soft palate, tonsils and adenoids, nasal cartilage, and throat muscles are contributing factors, and to advise the patient on specific procedures. It may be necessary for the patient to undergo more than one type of treatment for snoring, as some surgical procedures correct only one or two structures in the nose or throat.

A complete airway examination consists of an external examination of the patient’s face and neck; an endoscopic examination of the nasal passages and throat; the use of a laryngeal mirror or magnifying laryngoscope to study the lower portions of the throat; and various imaging studies. The otolaryngologist may use a nasopharyngoscope, which allows for evaluation of obstructions below the palate and the tongue, and may be performed with the patient either awake or asleep. The nasopharyngoscope is a flexible fiberoptic device that is introduced into the airway through the patient’s nose. Other imaging studies that may be done include acoustic reflection, computed tomography (CT) scans, or magnetic resonance imaging (MRI).

In addition to the airway examination, patients considering surgical treatment for snoring must make an appointment for sleep testing in a specialized laboratory. The American Academy of Sleep Medicine recommends this step in order to exclude the possibility that the patient has obstructive sleep apnea. Sleep testing consists of an overnight stay in a special sleep laboratory. Before the patient goes to sleep, he or she will be connected to a polysomnograph, which is an instrument that monitors the patient’s breathing, heart rate, temperature, muscle movements, airflow, body position, and other measurements that are needed to evaluate the cause(s) of sleep disorders. A technician records the data in a separate room. As of 2003, some companies are developing portable polysomnographs that allow patients to connect the device to a computer in their home and transmit the data to the sleep center over an Internet connection.

Preparation
Apart from the extensive diagnostic testing that is recommended, preparation for outpatient snoring surgery is usually limited to taking a mild sedative before the procedure. Preparation for UPPP requires a physical examination, EKG, blood tests, and a preoperation interview with the anesthesiologist to evaluate the patient’s fitness for general anesthesia.

Aftercare
Aftercare following outpatient snoring surgery consists primarily of medication for throat discomfort, particularly when swallowing. The patient can resume normal work and other activities the same day as the procedure, and speaking is usually not affected.

Risks
In addition to the risk of an allergic reaction to the local anesthetic, snoring surgery is associated with the following risks:
• Severe pain following the procedure that lasts longer than two to three days. This complication occurs more frequently with LAUP than with somnoplasty or injection snoreplasty.
• Causation or worsening of obstructive sleep apnea. LAUP has been reported to cause OSA in patients who had only primary snoring before the operation.
• Nasal regurgitation. This complication refers to food shooting or leaking through the nose when the patient swallows.
• Dehydration. This complication has been reported with the tongue suspension procedure.
• Permanent change in the quality of the patient’s voice.
• Recurrence of primary snoring.

Normal results
In general, surgical treatment for snoring appears to be most effective in patients whose primary problem is nasal obstruction. The results of snoring surgery depend to a large degree on a good “fit” between the anatomy of a specific patient’s airway and the specific procedure performed, as well as on the individual surgeon’s skills.

Morbidity and mortality rates
Mortality rates for UPPP are related to complications of OSA rather than to the procedure itself. With regard to the outpatient procedures for snoring, mortality rates are very close to zero because these surgeries are performed under local anesthesia. Complication rates, however, are high with both UPPP and LAUP. According to one European study, as many as 42% of patients have complications following UPPP, with 14% reporting general dissatisfaction with the results of surgery. Specific complication rates for UPPP are 15% for recurrence of snoring; 13% for nasal regurgitation; 10% for excessive throat secretions; 9% for swallowing problems; and 7% for speech disturbances. Complications for LAUP have been estimated to be 30–40% for recurrence of snoring; 30% for causing or worsening of OSA; 5%–10% for persistent nasal regurgitation; 1% for permanent change in vocal quality.

As of early 2003, no morbidity figures have been published for somnoplasty or injection snoreplasty.

Alternatives
Oral devices and appliances
Oral appliances are intended to reduce snoring by changing the shape of the oral cavity or preventing the tongue from blocking the airway. There are three basic types of mouthpieces: those that push the lower jaw forward; those that raise the soft palate; and those that restrain the tongue from falling backward during sleep. To work properly, oral appliances should be fitted by an experienced dentist or orthodontist and checked periodically for proper fit. Their major drawback is a low rate of patient compliance; one German study found that only 30% of patients fitted with these devices were still using them after four years. In addition, oral appliances cannot be used by patients with gum disease, dental implants, or teeth that are otherwise in poor condition.

Continuous positive airway pressure (CPAP) devices
CPAP devices are masks that fit over the nose during sleep and deliver air into the airway under enough pressure to keep the airway open. If used correctly, CPAP devices can be an effective alternative to surgery. Their main drawback is a relatively low rate of patient compliance; the mask must be used every night, and some people feel mildly claustrophobic when using it. In addition, patients are often asked to lose weight or stop smoking while using CPAP, which are lifestyle adjustments that some would rather not make.

Lifestyle changes
Patients who snore only occasionally or who are light snorers may be helped by one or more of the following changes without undergoing surgery:
• Losing weight and getting adequate physical exercise.
• Avoiding tranquilizers, sleeping pills, antihistamines, or alcoholic beverages before bedtime.
• Quitting smoking.
• Sleeping on the side rather than the back. One do-ityourself device that is sometimes recommended to keep the patient turned on his or her side is a tennis ball placed inside a sock and attached to the back of the pajamas or nightgown. This approach seems to work for some patients with simple snoring.
• Tilting the head of the bed upward about 4 in (10 cm).

Complementary and alternative (CAM) approaches
There are three forms of alternative treatment that have been shown to be helpful in reducing primary snoring in patients with histories of nasal congestion or swollen tissues in the throat. The first is acupuncture. Treatments for snoring usually focus on acupuncture points on the stomach, arms, and legs associated with the production of excess mucus. Insertion of the acupuncture needles at these points is thought to stimulate the body to release the excess moisture or phlegm. Homeopathy and aromatherapy also appear to benefit some patients whose snoring is related to colds, allergies, or sore throats. Homeopathic remedies for snoring are available as nose drops and throat sprays as well as the traditional pill formulations. Aromatherapy formulas for snoring typically contain marjoram oil, which may be used alone or combined with lavender and other herbs that clear the nasal passages. Some people find aromatherapy preparations helpful alongside mainstream treatments because their fragrance is pleasant and relaxing.