Office-Based Snoring Procedures

Introduction

“Primary snoring” can be described as a symptomatic, sleep-related, respiration-dependent acoustic phenomenon with an apnea-hypopnea index (AHI) of less than 5 and without complaints of daytime sleepiness. Snoring is common; it is estimated that 35% to 45% of men and 15% to 28% of women snore regularly. Current evidence regarding the medical morbidity of snoring is inconclusive. Population-based studies have been contradictory regarding the effect of snoring on mortality, cardiovascular disease, metabolic syndrome, and stroke. Like mild obstructive sleep apnea (OSA), treatment of snoring is still commonly considered elective and optional depending on the implications on the patient’s sleep and that of his or her bed partner. Snoring is the most common presenting symptom in sleep-disordered breathing patients, and therefore otolaryngologists should be aware of the proper workup as well as procedures and therapies available to treat this condition.

Numerous medical therapies are available for snoring, including various over-the-counter (OTC) options. Several common OTC choices, such as lubricating oral spray, nasal dilator strips, and snoring pillows, were not shown to be individually beneficial in a randomized, blinded clinical trial. Oral appliances have been shown to significantly reduce snoring, theoretically by increasing the size of the pharyngeal airway in both the lateral and the anterior-posterior dimensions. If oral appliances are used, follow-up is necessary to monitor the occlusion and dental health long term. Like available OTC snoring aids, oral appliance therapy is also limited by the requirement of regularly nightly use of the device.

Snoring is caused by the vibration of soft tissues in the upper airway during respiration; these vibrations are exacerbated by sleep-related relaxation of upper airway dilator muscles. The source of vibration is typically the flutter of the soft palate but can theoretically be anywhere along the upper airway. Surgeries addressing the patency of the nasal airway may help snorers who complain of nasal obstruction. The details of such procedures are discussed in detail elsewhere in this text. As a majority of snoring originates at the soft palate, the focus of the remainder of this chapter will be on awake, office-based palatal procedures. All of these procedures have the end goal of stiffening and/or reorienting the palate such that inhalation-induced vibration will be less likely to occur.

Key Operative Learning Points

1.
Snoring procedures must minimize morbidity and preserve function, especially as snoring is generally considered to be medically benign.
2.
When choosing the appropriate snoring procedure, the patient’s upper airway anatomy as well as social and financial concerns should be taken into consideration.
3.
Long-term follow-up after any of these procedures is necessary in order to monitor for return of snoring symptoms or signs of progression to OSA.

Preprocedure Period

History

1.
History of present illness
- a.
  Quality, quantity, and intensity of the snoring itself: A visual analog scale (VAS) can be helpful in quantifying the subjective intensity of snoring and can help assess the effect of treatment over time.
- b.
  Aggravating factors
  - 1)
    Position
  - 2)
    Medications
  - 3)
    Alcohol consumption
  - 4)
    Weight gain
- c.
  Presence of symptomatic nasal obstruction
- d.
  Sleep history: A full sleep history is warranted to assess for possible underlying and/or accompanying sleep disorders.
  - 1)
    Nocturnal apneas
  - 2)
    Daytime sleepiness
  - 3)
    Insomnia symptoms
  - 4)
    Morning headaches
  - 5)
    Restless sleep
  - 6)
    Nocturia
2.
Past medical history
- a.
  Prior medical or surgical treatment for snoring or sleep-disordered breathing
- b.
  Medical illness: The patient must be healthy enough to tolerate an in-office procedure.
- c.
  Social history
  - 1)
    Nicotine use: Abstaining from nicotine may help maintain a regular overall sleep-wake cycle.
  - 2)
    Alcohol use: This can affect quality of sleep directly and can increase snoring by reducing upper airway muscle activity.
- d.
  Medications
  - 1)
    Sleep aids, benzodiazepines, and other sedating medications that impact central or peripheral control of breathing during sleep
  - 2)
    Anticoagulant drugs that may increase the risk of bleeding during the procedure
  - 3)
    Allergies to antibiotics

Physical Examination

1.
Nasal cavity, including nasal endoscopy
- a.
  Septal deviation
- b.
  Turbinate hypertrophy
- c.
  Nasal polyposis
- d.
  Adenoid hypertrophy
2.
Oral cavity
- a.
  Dentition, including width and depth of the dental arches
- b.
  Occlusion
3.
Oropharynx
- a.
  Length of the soft palate
- b.
  Size of the uvula
- c.
  Hypertrophy of the tonsils
- d.
  Hypertrophy of the lateral oropharyngeal wall
4.
Craniofacial morphology
- a.
  Retrognathia
- b.
  Maxillary retrusion
5.
Overall body habitus, including body mass index (BMI): Weight reduction is often accompanied by a reduction in snoring and should be recommended for every overweight patient presenting with snoring.
6.
Flexible laryngoscopy
- a.
  Sagittal configuration and length of the soft palate
- b.
  Size and compliance of the lateral oropharyngeal walls
- c.
  Size and position of the base of the tongue
- d.
  Shape and collapsibility of the epiglottis
- e.
  Muller’s maneuver, an attempted inspiration with closed nose and mouth, may help identify problem areas with a tendency to obstruct.

Imaging/Testing

1.
Sleep laboratory testing: A sleep study, either via home portable monitoring or in-lab polysomnography (PSG), is required to rule out the presence of OSA and other sleep disorders in those seeking treatment for snoring.
2.
Drug-induced sedated endoscopy (DISE): DISE refers to flexible endoscopy performed on the sedated patient during spontaneous respiration. Sedation is typically achieved with propofol infusion. DISE may be considered if there is confusion regarding the anatomic source of snoring after clinical examination and flexible endoscopy. DISE may improve surgical success rates compared to clinical bedside examination in cases of snoring and OSA.
3.
Allergy testing: In snoring patients with symptomatic nocturnal nasal obstruction and symptoms of allergic rhinitis, allergy testing may indicate a reversible cause. A trial of medical therapy for allergy may also be beneficial to determine the impact of the rhinitis and nasal resistance on the patient’s snoring.
4.
Lateral cephalometric radiograph: Imaging is not routinely indicated for primary snoring but may be helpful in cases of skeletal abnormalities.

Indications

1.
Primary snoring in the setting of significant burden on the patient or bed partner

Contraindications

1.
Patient factors
- a.
  Inability to tolerate awake, office-based intervention
- b.
  Allergy to local anesthetic
- c.
  For palatal procedures, pre-existing velopharyngeal insufficiency (VPI) or cleft palate
- d.
  Trismus or other oral anatomy (e.g., large torus palatinus) precluding adequate awake access to the soft palate
- e.
  Relative contraindication: Obesity is associated with lower success rates for snoring procedures; this should be discussed preoperatively.
2.
Disease factors
- a.
  Underlying OSA: Procedures for primary snoring are not appropriate management in the setting of untreated moderate to severe OSA.
- b.
  Comorbid sleep disorders should also be addressed prior to procedures for primary snoring.

Preprocedure Preparation

Discontinue anticoagulant drugs if possible; however, the use of anticoagulants is not an absolute contraindication to these procedures.

Procedures

Anterior Palatoplasty

When uvulopalatopharyngoplasty (UPPP) was first introduced and became widespread in the 1990s, the procedure involved relatively radical tissue resection that often resulted in common and bothersome adverse side effects. In the ensuing years, several less invasive, functional versions of the procedure were developed. One of these UPPP descendants, the traditional cautery-assisted palatal stiffening operation (CAPSO), has been employed for snoring and involves the removal of a midline strip of palatal mucosa in the anterior-posterior direction. Though this procedure served to successfully stiffen the palate, the resulting scar was shown to narrow the distance between the tonsillar pillars laterally.

The modified CAPSO, or anterior palatoplasty, involves a horizontally oriented mucosal excision in the proximal soft palate. Resultant scarring and fibrosis not only stiffens the palate but also serves to pull the palate anteriorly and superiorly with healing ( Fig. 51.1 ). This procedure seems to be especially suited for patients with obstruction at the genu of the soft palate.

Fig. 51.1, A, Preoperative, B, intraoperative, and C, postoperative appearance of anterior palatoplasty.

Anesthesia

Local: If the patient requires only soft palate and uvula interventions, this procedure may be carried out under local anesthesia in the office setting.
General: If a patient is noted to have large tonsils, a tonsillectomy may be simultaneously indicated. When tonsillectomy is required, the anterior palatoplasty may be carried out under general anesthesia at the time of tonsillectomy.

Positioning

Seated: The patient should be sitting upright, at a level where the surgeon can comfortably visualize the oral cavity and oropharynx.
Tongue depressor(s) are typically required to visualize the soft palate. The cooperative patient may assist with exposure by holding his or her own tongue depressor(s).

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