Snoring surgery: Which one is best for you? - Statistical Data Included

Ear, Nose & Throat Journal, Nov, 1999 by Philip D. Littlefield, Eric A. Mair

Introduction

Snoring is a significant social problem that is commonly managed by the otolaryngologist. Approximately 20% of all adults--including nearly 50% of those over 60 years of age--are chronic snorers. [1] Snoring is the hallmark symptom of a spectrum of sleep-related breathing disorders collectively termed sleep disordered breathing. The patho-physiologic cause of sleep disordered breathing is sleep-induced airway obstruction. Minimal airway obstruction causes primary, or simple, snoring. On the other extreme, complete airway obstruction causes obstructive sleep apnea syndrome (OSAS).

OSAS traditionally receives more attention than does snoring because of its well-documented influence on mortality. It is now evident that untreated snoring also has medical implications, especially in some snorers who do not have OSAS but who manifest excessive daytime sleepiness (EDS). [2] In these patients, an elevated degree of airway resistance causes sleep fragmentation and EDS, but without the obstructive episodes of OSAS. The identification of this group resulted in the recognition of a new syndrome, intermediate between primary snoring and OSAS, called upper airway resistance syndrome. [3] Patients with this syndrome benefit from appropriate treatment.

The proper management of snoring begins with conservative measures that decrease airway resistance. Conservative therapy includes exercise, weight loss, decreased alcohol consumption, smoking cessation, altered sleeping position, and dental or nasal appliances. Although these measures often provide some benefit, patients generally do not obtain sufficient relief from their snoring. For this reason, surgery is the preferred treatment. [4]

Because excessive snoring is so common, there is an incentive to find a simple, safe, effective, and economical surgical remedy. Many procedures were developed during the past 2 decades, but which procedure, if any, is preferable is controversial. No single procedure has been proven to have the ideals that justify its sole use over others.

Our purpose is to review the snoring literature and to provide an objective overview of the four primary types of procedures now in use. Although some snoring surgeries are also used to treat OSAS, our intent is not to assess their merits in OSAS. OSAS is mentioned only when clinical issues make it relevant.

Although we primarily address palatal procedures, the airway obstruction that produces snoring can occur at several sites. The anatomic areas most often implicated in snoring are the retropalatal pharynx and retrolingual pharynx. [5] Several surgical procedures are available to correct each type of snoring, but the retrolingual procedures are more invasive and complicated than the palatal procedures. Nasal surgeries, such as septoplasty and inferior turbinate resection, rarely provide relief from snoring when used alone. [6] They are best used as an adjunct to more definitive surgical procedures. For these reasons, most patients who desire surgical treatment are initially offered a palatal procedure.

Several surgical procedures performed to treat retropalatal snoring are common, while others are more novel. Many procedures have similarities with others. For this review, we placed each procedure into one of four general categories: uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, palatal stiffening operations, and radiofrequency ablation (table). Based on our clinical experience with all of these procedures, we describe the advantages and limitations of each, and we offer clinical pearls that pertain to each technique.

Uvulopalatopharyngoplasty

In 1964, the Japanese surgeon Ikematsu described uvulopalatopharyngoplasty (UPPP), the first surgical treatment for snoring. [7] In 1981, Fujita introduced the procedure, with slight modifications, to the United States for the treatment of OSAS. [8] He soon realized that UPPP reduced snoring in his OSAS patients. Later, with more data, Fujita recommended UPPP to treat snoring in addition to OSAS. [9] The new procedure quickly became the gold standard.

In the technique described by Fujita, the patient undergoes a tonsillectomy, which is followed by a partial removal of the soft palate, uvula, and pharyngeal arches (figure 1) Finally, the mucosal edges are approximated with sutures. The procedure is performed under general anesthesia. The intended effect is to lessen snoring by allowing more room for airflow and by reducing vibratory tissue.

Early results indicated that UPPP was 75 to 100% effective in eliminating or significantly reducing snoring. [10-13] This was most encouraging, but as these patients were followed, it became apparent that the long-term success rates were not as good, ranging from 46 to 73%. [14-16] Koay et al specifically addressed this change in patient satisfaction and found that 13% of patients who had "successful" outcomes within the first postoperative year subsequently developed a recurrence of their snoring. [17]

The reasons for this decline in efficacy are not entirely known. The decrease in long-term success rates might represent a true increase in the incidence of snoring, or it might merely be a reflection of inexact measurements. Unfortunately, there is no standard way to measure intensity of a patient's snoring. Nearly all researchers rely on the subjective assessment of the patient's bed partner, and they use one of several scales to quantify the intensity of snoring. Attempts to objectively quantify intensity have met with only limited success. [18-19] For now, snoring is "in the ears of the beholder," because its capacity to irritate involves more than just decibels. [20]