Surgical Treatment for Snoring and Sleep Apnea
Snoring is a simple social problem caused by vibration of the soft palate and particularly disturbs other people sleeping with the person. Sleep apnea, on the other hand, is a serious problem characterized by the patient’s breathing stopping for at least 10 seconds together with snoring and this recurring more than 5 times within 1 hour. The disease we call sleep apnea is a serious condition that causes a severe clinical picture by leading to many systemic diseases and causes the person to remain tired and sleepy during the day. Although snoring and sleep apnea frequently occur together, this does not mean that every person who snores will have apnea.
Therefore, it is important first of all to distinguish simple snoring from sleep apnea. If it is simple snoring, we achieve highly successful results with sleep position training and radiofrequency applications to the nose and soft palate. However, in moderate to severe sleep apnea, we must choose different surgical procedures listed below in order or, if the patient can adapt, one of the CPAP, Automatic CPAP, or BiPAP devices. Mild sleep apnea can return to normal with nasal and radiofrequency surgeries. Since stopping snoring in sleep apnea patients may mask the condition and therefore be harmful, it is important to make this distinction first. In my own practice, I intensively performed some of the surgeries listed below in the past; in patients whose polysomnography index is between 5 and 15, if there is a significant anatomical problem, I perform sleep apnea surgery, or if there is a rare condition, I refer them to physician colleagues who deal with these conditions. Since the aim of sleep apnea treatment is to achieve long-term results, and because I do not believe the long-term results are very successful, I definitely recommend one of the CPAP, Automatic CPAP, or BiPAP devices to my patients with an index above 30 and almost never recommend surgery. You can contact us for information about Surgical Treatment for Snoring and Sleep Apnea.
Below, you can find more detailed information about the surgeries performed for this disease. Some of these are now almost never used, or each physician works on a specific region and its surgery. This disease is a problem involving many specialties, primarily ENT. I think it will become a separate medical specialty in the future. Statistics report that 4% of all people have obstructive sleep apnea, meaning that it is estimated that more than 3 million people in our country suffer from this disease. Correct differential diagnosis is very important for these patients, and in addition to preventive patient education, I intensively apply radiofrequency treatments to the nose, soft palate, tonsils, and base of the tongue. In addition, the general condition of patients and other medical problems such as high blood pressure, diabetes, and heart disease also play an important role in making the surgical decision.
Parameters Indicating the Need for Surgery in Apnea Patients:
- An RDI (Respiratory Disturbance Index) above 5 in the sleep analysis (Polysomnography),
- Blood oxygen saturation detected below 90% in polysomnography,
- Complaints such as daytime sleepiness affecting daily life,
- Presence of a significant heart rhythm disorder,
- Detection of significant anatomical problems explaining the complaints during the patient’s examination,
- Inability to adapt to CPAP treatment,
- Absence of a medical problem that would prevent surgery.
A. SURGERIES FOR THE SOFT PALATE
The aim of this type of surgery is to increase the volume of the air passage behind the uvula and soft palate and to reduce the tendency of the tissues to collapse. Although it is the most frequently operated region, the problem is limited only to this region in just one-quarter of patients.
In nearly half of the patients, there is also a problem in the base of the tongue or nasal region together with the palate. As a result, it can be said that 75% of patients have a soft palate and uvula problem to a greater or lesser extent.
The type of surgery to be performed on the soft palate varies according to the severity of the problem and the cause of airway obstruction. When deciding on the intervention to be performed, in addition to the sleep analysis, the uvula, soft palate, posterior lateral walls of the throat (lateral pharyngeal bands), and tonsils should be carefully evaluated.
Click the link for the technique we apply to the soft palate and uvula
From the past to the present, there are generally five types of surgical approaches:
1. Palatal radiofrequency applications:
It is based on the principle of creating heat damage that heals with contraction and stiffening in the tissues beneath the mucosa and in the palatal muscles by delivering radiofrequency energy into the soft palate tissue. As a result, the tendency of the soft palate to vibrate and collapse due to the vacuum created by airflow decreases. The procedure can be performed under local anesthesia in office conditions (Figure 1).
It is preferred in patients in whom thickening, degeneration, and sagging of the soft palate are limited, generally those with snoring complaints but no significant apnea, or patients with a mild soft palate problem in whom the main pathology causing apnea is located in other regions. Better results are achieved in patients with a body mass index below 25, while the results gradually worsen at values above 25.
2. Soft palate implant application (Pillar Implant):
The Pillar Procedure is the process of placing three small implants into the soft palate to reduce the vibration of the soft palate that contributes to the snoring sound and its looseness that causes airway obstruction, which is one of the anatomical components of sleep apnea and snoring (Figure 2). When these implants are placed, they provide structural support to the soft palate. Over time, the body’s natural tissue fuses with these implants, increasing the structural integrity and firmness of the soft palate.
Pillar implants are designed so that they are not visible inside the mouth and are not felt during swallowing or speaking, and do not interfere with swallowing or speaking. The implants can also be placed under local anesthesia in office conditions, and most patients can return to their normal diet and activities on the day of the procedure. This treatment method is preferred in patients who are found to have simple snoring or mild sleep apnea as a result of sleep analysis and who do not have advanced deformity of the soft palate on physical examination.
The Pillar procedure can also be applied in combination with other surgeries for snoring and apnea.
As with radiofrequency, better results are obtained from this procedure in patients with a body mass index below 25.
3. Shortening the uvula (Uvulectomy):
The function of the uvula is to direct the food bolus toward the upper part of the esophagus during swallowing, prevent food from entering the nasopharynx, and facilitate the passage of mucus drainage from the nasopharynx into the esophagus.
Excessive snoring may cause the uvula to become edematous, elongated, and thickened over time. In a very small proportion of patients, the cause of snoring and sleep apnea is solely a long and/or thick uvula. Therefore, uvulectomy alone is performed only in highly selected cases. Although complications of uvulectomy are uncommon, bleeding may occur.
4. Laser uvulopalatoplasty:
It is a technique that began to be used frequently with the introduction of LAUP (Laser Assisted Uvulo-Palatoplasty) in the early 1990s and can also be performed under office conditions. There are differing opinions recommending its use only in cases of simple snoring or in cases of mild to moderate sleep apnea.
The most important problem with laser LAUP is the severe pain that occurs after the procedure. This disadvantage has led to the technique being largely abandoned in recent years.
5. Uvulopalatopharyngoplasty (UPPP):
It is the most frequently performed surgical technique in patients with sleep apnea syndrome. It is fundamentally based on reducing the volume formed by the uvula, soft palate, and tonsils (Figure 3). It is reported to be successful in 85% of patients with simple snoring and in 25-75% of patients with sleep apnea syndrome. After UPPP surgery, temporary passage of food into the nasopharynx (velopharyngeal insufficiency), bleeding, infection, postnasal drainage complaints, difficulty swallowing, taste disturbance, and numbness of the tongue may occur. Care should be taken during anesthesia in severely obese patients. The most common problem frequently reported by patients is postoperative pain. Although it gradually decreases after surgery, significant pain is frequently observed, especially during the first 5-7 days.
Dry mouth, a feeling of tightness, and postnasal drip, which may cause long-term complaints, result from the inability of the uvula to perform its function.
B. SURGERIES FOR THE BASE OF THE TONGUE
Following the soft palate region, the area behind the tongue is the region most commonly responsible for snoring and sleep apnea syndrome. Therefore, intervention in both regions may be necessary in many patients.
Especially in overweight patients with a high body mass index (BMI), losing approximately 10% of their body weight is highly likely to reduce complaints originating from the tongue base region. Therefore, in patients with an isolated tongue base problem and a high BMI, weight-loss techniques must be tried before planning surgery. In patients with significant soft palate pathology and moderate or severe apnea, surgery for the nose and palate may be performed first. In both groups, CPAP should be used during the weight-loss period if necessary.
There are various surgical methods applied to the tongue base region, whose surgery may be difficult for both the patient and the surgeon due to its location and where postoperative problems and even the risk of death are relatively higher.
1. Laser midline glossectomy:
It is the process of removing a 2.5×5 cm section of tongue base tissue from the midline of the tongue base with the help of a laser applied through the mouth. At the same time, reduction of the lymphoid tissue at the tongue base (lingual tonsils) and certain laryngeal structures may also be performed. After these surgeries, temporary placement of a tube into the airway through the neck (tracheotomy) is required because of the possibility of airway obstruction due to swelling or bleeding in the tissues.
2. Tongue plasty (Lingualplasty): In this approach, which involves the removal of a larger amount of tissue than laser midline glossectomy, opening a tracheotomy is also mandatory.
3. Tongue base radiofrequency applications:
By applying radiofrequency to the tongue base, a reduction in tongue base volume is expected as the damage developing within the tissue heals with firm scar tissue. The most important disadvantage of this method, which can also be applied under local anesthesia in office conditions, is the need to repeat it for 4-6 sessions in order to observe positive results. In sleep apnea patients with enlargement of the tongue base, it can be applied in combination with other surgeries during the same session. Compared with other methods applied in this region, the probability of complications is significantly lower, and it does not require tracheotomy.
3. Advancement of the genioglossus muscle in the floor of the mouth:
It is the operation that provides the greatest increase in volume in the tongue base region. With this technique, the genioglossus, the most important muscle that pulls the tongue forward, is pulled forward together with the bone area where it is attached to the inner part of the lower jawbone, thereby widening the area behind the tongue.
Since muscle relaxation (hypotonia) during sleep and complete immobility (atonia) during REM sleep cause the tongue to fall backward, tightening the genioglossus muscle prevents the tongue from falling backward during sleep.
C. OTHER TECHNIQUES
1. Hyoid myotomy and suspension of the hyoid bone:
The resistance of the airway to airflow in the area behind the tongue depends on the genioglossus muscle and the muscles attached to the bone called the hyoid in the neck. While advancement of the genioglossus resolves the problem related to this muscle and increases the volume behind the tongue, tightening the muscles attached to the hyoid bone prevents collapse of the air passage beneath the tongue base.
2. Suspension suture:
In this technique, after reaching the inner part of the lower jawbone through the floor of the mouth or through an incision made beneath the chin, a screw is placed in this region with a special device. Then, a non-absorbable thread attached here is passed through the base of the tongue with the help of a special needle, turned to the other side, and tied. There may be difficulty with nutrition for a few days after surgery. The most important complication of this approach is the development of swelling (edema) in the tissues after surgery. The operation does not cause significant restriction in tongue movements, but it partially reduces the movement of the tip of the tongue. Although the early results are good, success decreases over time as the suture slips within the tissue.
3. Advancement of the upper and lower jawbones (Maxillomandibular osteotomy and advancement):
The operations mentioned above are first-phase techniques for the area behind the tongue. If the first phase is unsuccessful or inadequate, second-phase surgeries are considered. Maxillomandibular advancement is a major operation involving moving the middle part of the face, hard palate, and mandible forward. In this surgery, the posterior airway is widened and the genioglossus is tightened. In addition, the oral cavity volume is increased. Bone pieces taken from other parts of the body must be placed between the displaced bones. Although it is highly effective in apnea patients, it is performed very rarely by surgeons specializing in this field because the recovery process is long and follow-up is quite difficult (in this surgery, the facial bones are fractured on both sides and the midface is pulled forward).
4. Nasal surgeries:
The nose and nasopharynx should be examined in every patient presenting with snoring and sleep apnea. In many patients, a problem such as deviation inside the nose or enlargement of the turbinates is encountered.
In patients without significant pathology in the palate and tongue base and in CPAP candidates, if there is severe nasal obstruction, this problem should be resolved first.
In patients in whom intervention in the palate or tongue base region is planned, if nasal intervention will be performed during the same session, the use of techniques that do not require nasal packing will make the postoperative period more comfortable.
5. Placement of a Cannula into the Airway Through the Neck (Tracheotomy):
Tracheotomy is required in two situations in patients with sleep apnea. The first group consists of patients with severe sleep apnea, very low O2 saturation, heart rhythm problems, who have used CPAP but have not benefited sufficiently. If the RDI is above 50, O2 saturation is below 60%, and/or there is a serious heart rhythm disorder, a tracheotomy should be opened. The second group consists of patients at risk of upper airway obstruction due to postoperative edema. Since the upper airways are bypassed, it is a definitive solution for apnea, but living with a permanent opening in the throat is the last solution patients would want.
POSTOPERATIVE FOLLOW-UP:
Patients with an RDI above 20 and serious heart rhythm problems should be considered at risk and should be monitored in intensive care for one day after surgery.
Almost all patients require painkillers at varying levels after surgery. It is easier to control pain during hospitalization. A good pain-management plan should be prepared following discharge. Postoperative pain may continue for up to two weeks while gradually decreasing. Following surgery of the palate and the area behind the tongue, antibiotics should be administered to prevent regional wound infection; otherwise, the severity and duration of difficulty swallowing and pain complaints will increase. Patients should be discharged once they begin to receive sufficient nutrition orally and their pain is brought under control.
The causes of obstruction developing in the same anatomical region after surgery are an inadequate surgical approach, excessive soft tissue laxity, or regional fat accumulation due to the patient’s weight gain.
Patients who do not accept treatment or cannot be treated with appropriate methods may develop conditions such as hypertension, heart failure, and cardiovascular diseases over time. As the RDI scores of patients increase, the frequency of such problems should be expected to increase.
ISSUES TO CONSIDER IN SLEEP APNEA SYNDROME SURGERIES:
- In patients whose RDI is detected above 40 and/or whose blood oxygen saturation is below 80% in the sleep analysis (Polysomnography), CPAP should be applied for two weeks before surgical intervention. CPAP use should be continued after surgery until a follow-up polysomnography is performed. In patients in this group who cannot tolerate CPAP and BiPAP, a tracheotomy should be opened during surgery.
- Before the operation, the use of medications and substances that may have sedative and respiratory-suppressing effects should be avoided, and while the patient is being anesthetized, the surgeon should be present in the operating room in case emergency intervention is required.
- The tube placed in the airway during anesthesia should be removed only after the patients are fully awake. Early removal of the tube may lead to spasm and closure of the larynx (laryngospasm).
- Patients who undergo surgical procedures in multiple regions and/or who have significant heart-lung disease should be monitored in intensive care for 1 night after surgery.,
- Patient-controlled pain management systems (PCA-Patient Controlled Analgesia) should be used carefully after surgery, and painkillers that affect respiration should not be used.
- Patients should be discharged only after they can receive sufficient nutrition orally, satisfactory pain control has been achieved, and surgery-related edema has sufficiently subsided.
