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Sleep & Snoring Department
Snoring & Sleep ApneaMillions of Americans and their sleep partners are affected by snoring. This can be an isolated problem or a symptom of a more severe sleep disturbance such as obstructive sleep apnea. A thorough evaluation is needed to identify the sleep disorder and provide the best treatment options. For benign snoring, several office procedures under local anesthesia are available to improve snoring. Nasal obstruction can also contribute to snoring and may require additional medical or surgical treatments. Sleep apnea - Snoring can be a sign of sleep apnea, where breathing stops or is suppressed during sleep. Symptoms can include:
Sleep apnea can result in a drop in the oxygen level in the blood during sleep causing a significant strain on the heart and lungs. Contributing factors to sleep apnea include nasal obstruction, enlarged tonsils, elongated palate and weight gain. A thorough head and neck examination and sleep study are frequently used to diagnose this disorder. Several medical and surgical treatments are available. Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, or several of these areas at the same time. Each surgery's success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
Many people have several levels of obstruction, therefore these surgical techniques frequently are performed together, for example, uvulopalatopharyngoplasty with genioglossus advancement and hyoid suspension. Nasal airway surgeryIt is rare for obstructive sleep apnea to be caused by nasal obstruction alone. The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP. Nasal obstruction makes CPAP difficult if not impossible to tolerate. Surgery to open the nasal passages markedly improves tolerance to CPAP. Palate implantsPalate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring. Palate implants have now been approved for people with mild sleep apnea who have palatal collapse. A study in people with an apnea-hypopnea index of less than 24 demonstrated a 44% success rate in decreasing the apnea-hypopnea index by 50% with a final apnea-hypopnea index less than 10 (Pillar Implant clinical trial). Palate implants can be successful for a small group of people with mild sleep apnea and palate collapse; however, a 250 pound man with an apnea-hypopnea index of 50 and decreases in blood oxygen of 85% will probably not be cured with a palate implant. The Pillar® ProcedureThe Pillar Procedure is an effective and less invasive treatment for people suffering from sleep apnea. During a brief office visit your ENT physician will administer a local anesthetic and then inject three small implants in your soft palate to help stiffen the pallet to reduce snoring and airway obstruction during sleep. You should not be able to feel these implants and, other than some minor pain up to 24 hours after the procedure, you can return to normal eating habits and should experience more restful sleep. Pillar Snoring & Sleep Apnea Treatment Video Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. A UPPP operation is performed under general anesthesia (the patient is completely asleep). In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. All of the surgical cuts are closed with stitches. UPPP usually requires an over night stay in the hospital to monitor breathing. Tongue reduction surgeryIn some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures. Laser midline glossectomy is one method to decrease the size of the tongue. Under general anesthesia, a laser is used to cut a trough down the middle of the base of the tongue. The difficulty with this procedure is to remove enough tissue to prevent collapse without changing the natural functions of the tongue during speaking and swallowing. This procedure often is used for people who have had a UPPP but continue to have obstructive sleep apnea. Combined with other surgical procedures, laser midline glossectomy has been reported to be 70% successful. The tongue base has also been the focus of surgical procedures to shrink the base of the tongue by scarring (tissue that scars usually shrinks in size). For example, radiofrequency energy has been used to injure and scar the base of tongue. Usually the first treatment is performed under general anesthesia. A radiofrequency probe is placed in the muscle of the back of the tongue and energy is delivered. Over time, the tissue scars and shrinks. Frequently, several treatments are applied to the tongue. The later treatments can be performed in the office. A 17% reduction in volume of the tongue has been measured using this technique; however, this is generally not a successful technique if it is used alone. Therefore, reduction of the base of the tongue is frequently used with UPPP or other procedures. Genioglossus advancementThe genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. There are a several procedures that pull the tongue forward to enlarge the airway. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. Genioglossus advancement is performed under general anesthesia and requires cutting the bone and screwing it back in place. This usually is performed in combination with hyoid suspension or UPPP. There also are less invasive methods to advance the genioglossus muscle. One method uses a stitch through the base of the tongue that attaches to a screw on the inside of the jaw. Hyoid SuspensionThe hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like a UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up. This procedure is very rarely done alone without other surgical procedures. Like other surgical procedures for obstructive sleep apnea, hyoid suspension has an adequate success rate when performed in an appropriately selected patient. TracheostomyA tracheostomy is a procedure to bypass the narrowed airway. The trachea is the specialized tube that connects our larynx (voice box) to the lungs. It can be felt in the lowest part of the neck in most people. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. This surgery is performed under general anesthesia and requires observation post-operatively for complications in the intensive care unit. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night. A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve. Studies have shown improvements in sleepiness, hypertension, and cardiac risks following tracheostomy.
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