Snoring

Effective treatment is available for almost all patients. The treatment of snoring requires a multidisciplinary and logical approach, and is divided into medical and surgical options. The therapeutic choice is individualised. A ‘staged’ approach is often used, which involves medical therapy first, followed by consideration of surgery.

Conservative Treatment

Conservative treatment includes eliminating outside factors that may be playing a role in snoring. These include:

• Weight loss
• Avoidance of alcohol or other medications
• Treatment of nasal congestion with medications
  As nasal obstruction increases the frequency of snoring and sleep-disordered breathing, oral medications prescribed or recommended by your physician are available to help you breathe through your nose during sleep.
• Nasal CPAP (continuous positive airway pressure) can supply pressurised air into the upper airway via a nasal mask, keeping the upper airway open. CPAP is not usually prescribed for snoring unless there is associated apnoea.
• Dental appliances that hold the jaw in a forward protrusive position during sleep have also been used to treat snoring.

Surgical Treatment

Surgical procedures for the treatment of snoring may include nasal, palate, jaw, tongue or neck surgery depending on the location of the tissues contributing to the snoring.

Most treatments are directed at the soft palate (soft tissue at the back of the roof of the mouth) since this is the most common site of snoring. Surgery of the soft palate is effective in 80-90% of cases and can be associated with postoperative pain for 7-10 days.

Certain nasal conditions can cause snoring and require assessment by an ear, nose and throat (ENT) surgeon. Some snorers have excessive tissue such as large tonsils, long palate and bulky tongue. Removal of such excessive tissues will help alleviate snoring.

Types of surgery include:

• Nasal Surgery
  Nasal airway obstruction caused by bony, cartilaginous or enlarged tissues can interfere with nasal breathing during sleep. An open nasal airway establishes normal breathing and minimises mouth breathing. Mouth breathing in OSA individuals worsens the posterior airway by allowing the tongue to fall back.
  
  Establishing an open nasal airway passage can improve CPAP tolerance and compliance. Techniques include straightening the septum, turbinectomy and nasal valve reconstruction.
• Palatal Surgery
  Abnormal structures at the palate level include large tonsils, redundant lateral pharyngeal mucosal, thick and long soft palate and hypertrophied posterior tonsillar pillar muscles and mucosal. All these contribute to a narrow airway at the palatal level.
  
  The traditional Uvulopalatopharyngoplasty (UPPP) and many variations of it can be used. Most surgeons have shied away from the traditional UPPP in favour of modified techniques and surgical flaps (like uvulopalatal flap, extended uvulopalatal flap, lateral pharyngoplasty) as these have fewer complications, are less ablative and have a higher success rate.
  
  In carefully selected patients, the success rate may be 50-60% but falls to a low of 5-30% in unselected patients. This is because of the failure to address tongue base and hypopharyngeal obstruction.
• Hypopharyngeal and Base of Tongue Surgery
  Compared to the nasal and oropharyngeal level, obstruction at the hypopharyngeal (base of tongue) level is a very complex issue as the large tongue base tissue collapses easily during sleep.
  
  Obstruction at this level may be bypassed via a tracheotomy or by either increasing airway size to make more room for the tongue or reducing the tongue size. Both soft tissue techniques and skeletal work may be required.
  
  Soft tissue work involves removing the midportion of the tongue (median glossectomy, lingualplasty or volumetric reduction by radiofrequency).
  
  Skeletal advancements techniques can increase the airway size and tension on the tongue so that even if the tongue falls back during sleep it does not obstruct the airway. This procedure includes inferior sagittal mandibular osteotomy and genioglossus advancement and hyoid procedures.
• Maxillomandibular Advancement Surgery
  Maxillomandibular advancement surgery is a more aggressive procedure, usually saved for when the more conservative surgery fails. It involves the forward movement of the lower jaw and midface and gives the tongue more room, opens the airway more and places additional tension on the tongue base. The individualised use of staged soft tissue and skeletal procedures for upper airway reconstruction ensures that the most conservative treatment is offered and the possibility of unnecessary surgery reduced.
• Tracheostomy
  Tracheostomy involves creating a hole in the trachea, directly bypassing the upper airway obstruction. It is used in people with refractory base of tongue obstruction and in the morbidly obese with medical conditions that contraindicate surgeries that are more extensive. Though the success rate is 100%, this option is usually not accepted by patients and with the introduction of CPAP, it is seldom used.

Radiofrequency Thermal Ablation

Radiofrequency thermal ablation of the soft palate and tongue (somnoplasty) is also used to treat snoring. It stiffens and shrinks the tissues of the soft palate and tongue base.