Managing snoring: When to consider surgery
ABSTRACTSnoring can range in significance from merely annoying the patient’s bed partner to being a symptom of obstructive sleep apnea, a risk factor for heart disease and stroke. If conservative measures do not help, primary care physicians can refer patients for consideration of a variety of surgical procedures to keep the airway open during sleep.
KEY POINTS
- The treatment of snoring begins with a thorough history and physical examination.
- Polysomnography is almost always necessary to rule out other sleep disorders, such as obstructive sleep apnea. This is particularly important if an elective surgical intervention is planned.
- Surgical procedures for snoring include septoplasty with or without radiofrequency ablation of the upper airway, injection snoreplasty, Pillar implants, and laser-assisted uvulopalatoplasty.
- Although studies indicate that these procedures are effective, no well-controlled study has compared one procedure against another. The choice of procedure is often determined by the expertise of the surgeon, and the outcome is highly dependent on the skill of the surgeon.
SURGICAL PROCEDURES
Septoplasty
Septoplasty—straightening the nasal septum to improve the nasal airway—is an outpatient procedure. Although a deviated septum alone is not often the sole cause of snoring, most otolaryngologists agree that the septum should be addressed before or concomitantly with any palatal surgery for sleep-disordered breathing.
Nasal congestion often comes from a deviated bony or cartilaginous septum, enlarged turbinates, or bone spurs. Septal deviation may be developmental or the result of trauma to the nose.
Complications of septoplasty are rare but include septal perforation, scar-band formation, septal hematoma, epistaxis, and infection.
Radiofrequency ablation of the inferior turbinates
Hypertrophy of the inferior turbinate is the most common cause of nasal obstruction, followed by structural deformity of the nasal airway by septal deviation.3 Many patients report fixed or fluctuating nasal congestion and chronic mouth-breathing. The causes of turbinate congestion or enlargement include allergic rhinitis, upper-respiratory infection, and chronic rhinitis. In most cases, turbinate hypertrophy occurs at the level of the submucosa.
Radiofrequency ablation uses radiofrequency energy to generate heat at approximately 85°C (185°F) to create finely controlled coagulative lesions. The lesions are naturally resorbed in 3 to 8 weeks, inducing fibrosis, reducing excess tissue volume, and thus opening the airway. The procedure can be repeated several times to achieve optimal results. Radiofrequency ablation can also be used to reduce anatomic obstruction in other parts of the airway, such as the soft palate and the base of tongue.
Submucosal radiofrequency ablation of the inferior turbinate is a simple office-based procedure. It is often combined with septoplasty to optimize the nasal airway.
Mild to moderate edema with subsequent nasal obstruction and thick mucus formation can be expected the first week after the procedure. The risk of postoperative bleeding and infection is low. When performed with septoplasty, there is a low risk that scar tissue, or synechiae, may form between the turbinate and the septum.
Radiofrequency ablation of the palate
The soft palate is the most common anatomic source of snoring, and radiofrequency ablation can be applied to it as well. As with radiofrequency ablation in other areas, coagulative necrosis leads to fibrosis, and the soft tissue eventually contracts in volume with increased stiffness, thereby resulting in less tissue elasticity and vibration.
Carroll et al10 reported that nasal surgery combined with radiofrequency ablation of either the palate or the base of the tongue completely resolved snoring (according to the patient’s bed partner) in 42% of cases and improved it in 52%, with few complications. Also, patients who received more than one radiofrequency ablation application were more than twice as likely to have resolution of their snoring.
A systematic review of palatal radiofrequency ablation for snoring found that it is safe with minimal complication rates and reduces snoring in short-term follow-up.11 The authors reviewed 30 studies: two randomized controlled trials, four clinical controlled trials, and 24 prospective uncontrolled studies. The only placebo-controlled randomized controlled trial found soft-palate radiofrequency ablation to be superior to placebo. In these studies, follow-up varied from 6 weeks to 26 months. However, the relapse rate was as high as 50% at a mean follow-up time of 13.2 months.
Thus, most of the information in this review has come from observational studies with short follow-up time. In another study, however, the authors presented a 5-year follow-up of palatal radiofrequency ablation that showed persistent and satisfying reduction of snoring.12
Injection snoreplasty
Alternative procedures have been used to reduce palatal flutter that leads to snoring.
Injection snoreplasty was first described by Brietzke and Mair al in 2001.13 Sodium tetradecyl sulfate, a sclerotherapy agent, is injected directly into the submucosal layer of the soft palate to induce scarring and reduce or eliminate snoring caused by the soft palate.
In a cohort study of 25 patients, the subjective success rate was 75% (13 patients) as far out as 19 months.14 In a separate cohort of 17 patients, home polysomnography with audio recordings was done before and after treatment in patients who underwent injection snoreplasty. Twelve (17%) of these patients had a significant reduction in the proportion of palatal snoring, loudness, and flutter frequency. Long-term success and snoring relapse rates of injection snoreplasty were reported to be similar to those of other current treatments.14
Pillar implants
The Pillar implant (Medtronic) was approved by the US Food and Drug Administration in 2002 for snoring and in 2004 for mild to moderate obstructive sleep apnea.
The implant, made of a woven polyester material, is designed to reduce vibration of the soft palate by increasing its stiffness. The implant induces a chronic inflammatory response that is thought to result in the formation of a fibrous capsule, which may also play a role in palatal stiffening. Three thin implants are inserted into the paramedian soft palate in a parallel orientation. This is an outpatient procedure done in the office.
The short-term benefits of the Pillar implant procedure have been well documented.15,16 A meta-analysis of seven case-controlled studies that included 174 patients found the Pillar implant significantly decreased the loudness of snoring by 59%.15 The major disadvantage of Pillar implants was their high extrusion rate, which was reported to be 9.3%.15 While statistically significant improvement has been shown at up to 1 year, a recent longitudinal study suggests a clinical deterioration in snoring scale scores by 4 years after the procedure.16
Laser-assisted uvulopalatoplasty
Laser-assisted uvulopalatoplasty is a staged office-based procedure that involves removal of excess uvular mucosa and the creation of transpalatal vertical troughs to widen the retropalatal airway for the treatment of snoring and mild obstructive sleep apnea. The treatment typically requires about three sessions. It aims to mimic the palatal appearance of uvulopalatopharyngoplasty used to treat obstructive sleep apnea and has been proposed to have similar surgical outcomes in properly selected patients.
Krespi and Kaeker,17 in 1994, were among the first to describe the technique in the United States.
Kyrmizakis et al,18 in a retrospective study of 59 patients with habitual snoring who underwent laser-assisted uvulopalatoplasty, showed that a significant number of patients benefited from the procedure. During a follow-up ranging from 6 months to 5 years (mean 40 months), 91.5% of the patients with habitual snoring reported significant short-term improvement based on a posttreatment questionnaire, and 79.7% reported long-term subjective improvement.
Unfortunately, most of the studies have been small, and thus there is some controversy about the efficacy of laser-assisted uvulopalatoplasty, particularly in patients with obstructive sleep apnea. The most significant complication during healing is pain, which may deter patients from completing the full course of treatment.
