Siamak N. Nabili, MD, MPH
Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.
In this Article
- Snoring facts
- What is snoring?
- How common is snoring?
- What causes snoring?
- The function of the nose in normal breathing
- How do medications and alcohol affect snoring?
- Why is snoring a problem?
- What is the clinical importance of snoring?
- What are different levels of snoring?
- How should someone with snoring be evaluated?
- How is it determined if snoring is a medical problem?
- What are some objective tests to measure sleepiness?
- What are the treatments for snoring?
- What are some non-surgical treatments for snoring?
- What are the surgical options for snoring?
- What is the success of surgery for snoring?
- Find a local Sleep Specialist in your town
What are the surgical options for snoring?
Surgery to treat snoring is designed to reduce obstruction or narrowing in the anatomic area that is causing the snoring. There may be more than one involved area, so surgery on only one of the narrowed areas may decrease snoring but not eliminate it entirely. Decreasing palatal and uvular flutter are also believed to help in reducing the snoring sounds.
Surgical treatment of snoring is generally focused on the nasal passages, palate and uvula, and tongue. Most of the surgical procedures are performed in a doctor's office. In general, individual insurance carriers determine what medical conditions are covered as a benefit of the plan. Insurance is frequently changing, and, therefore, coverage policies may vary. As always, it is important to check with your own insurance carrier and pre-confirm the estimated cost and coverage for any planned medical treatment or surgery.
It is prudent to undergo a formal sleep study (polysomnogram) prior to performing surgery to assure that snoring is not a manifestation of obstructive sleep apnea. If sleep apnea is the case, then more conservative CPAP needs to be prescribed and attempted first. In addition, if snoring is related to obstructive sleep apnea, then a surgical correction may mask the obvious symptom of a potentially serious condition and leave sleep apnea undiagnosed.
Nasal surgery options for snoring
Nasal surgery to treat snoring is generally focused on improving a narrow nasal passage. While improvements in snoring may occur after improvements in nasal breathing, some studies have not always shown this to be the case.
In the doctor's office, radio-frequency energy can be used to shrink the turbinates by creating scar tissue in them, resulting in a more open nasal passage. The procedure takes about 15 minutes. Most of that time is spent numbing the nasal tissue with topical and injectable medications.
The procedure is performed with a wand that is placed into the tissues. Radio-frequency energy then is released into the tissues for about ten seconds. Several applications are done on each side of the nose for maximal effect. The procedure is successful when scar tissue forms. Therefore, it takes about three months to see the full effect of the procedure. As the scar tissue softens over time, however, the swelling and narrowing may recur. The procedure then can be repeated as needed in the office.
Several other anatomic problems can cause or worsen snoring. The nasal septum is the "wall" in the center of the nose that separates the right and left nasal passages. After trauma (including during birth), the septum can be deviated to one side or may curve to both sides (one side by the front of the septum and the other by the back of the septum). The septum deviation can be corrected by removing the crooked cartilage. This surgery usually is performed in the operating room under general anesthesia. After surgery, if the nasal obstruction is improved, the snoring often improves.
Nasal polyps are mucosal "growths" in the nose that are usually caused by allergies. As they continue to enlarge over time, they can cause nasal obstruction. If the polyps are large enough, they will require surgery to remove them. This surgery was previously performed in the doctor's office. However, it is currently more usual to perform the surgery in the operating room under general anesthesia. Removing the polyps reduces nasal obstruction, which may improve snoring.
Oral surgery options for snoring
Snoring can also be caused by a long, floppy palate and uvula. There are several procedures that involve the uvula and palate. Some procedures remove the tissue whereas others try to stiffen the tissues. Because the procedures are performed on soft tissue, over time the tissue stiffening can soften. As a result, a reduction in the effect may occur.
Uvulectomy is the removal of the uvula. This can easily be performed under local anesthesia in the doctor's office. A person usually does not miss having the uvula. However, there is a period of one to two weeks of discomfort in the throat after the procedure. Some people require strong pain medications for several days, whereas others need only acetaminophen (Tylenol) or an over-the-counter equivalent. Most people describe the pain as similar to a bad viral sore throat that is worse when swallowing. The main risks of uvulectomy are pain, bleeding, and altered speech (if you speak a language with guttural fricatives like Hebrew or Farsi).
Laser assisted uvulopalatoplasty (LAUP)
Laser assisted uvulopalatoplasty (LAUP) is an older procedure which involves trimming the palate with a laser. It can be performed in the doctor's office under local anesthesia. Small cuts are made in the palate on each side of the uvula with a laser. Several procedures are usually needed for a maximal effect. The scarring caused by the procedure stiffens the palate, decreasing the ability of the palate to vibrate and pulls the palate sideways to tighten it. This procedure results in moderate pain for one to two weeks that is generally controlled with oral pain medications.
Other methods to stiffen the palate in the office include injections with a sclerosing agent, radiofrequency ablation of the palate, cold ablation of the palate, or in-office palatoplasty procedures.
Snoring due to a long, floppy palate can be treated with office procedures that stiffen the palate. Like a sail on a sailboat, the air moving around the palate can cause vibrations of the tissue. For a sailboat sail, battens are placed to stiffen the sail and decrease vibration. Similarly, a stiffer palate vibrates less. The palate can be stiffened by creating scar tissue (as discussed previously) or with implants.
Radio-frequency ablation of the palate
Radio-frequency ablation of the palate can be performed under local anesthesia in the doctor's office. Usually, three tunnels in the tissue are made with a radiofrequency wand. The radiofrequency energy is applied for approximately ten seconds with the wand in the palate muscle tissue. The tissue heals as scar tissue, and the palate becomes stiffer and vibrates less. Generally, scar tissue in the palate continues to form for up to three months. Up to 77% of people report reduced snoring after this procedure, however, as the tissue continues to heal over time, the palate may soften and re-obstruct. One study demonstrated a 29% relapse in snoring after one year.
Palate implants are now being used to treat snoring. They are made from Dacron, which is a non-reactive material that has been used for many years for heart valve surgery and hernia repair. Dacron also encourages the normal tissue to grow into it. Small Dacron implants are placed into the palate under local anesthesia. The implants stiffen the palate like scar tissue after radiofrequency treatments. The implants stay in the tissue, so recurrence of snoring should be reduced.
Correct patient selection is important. The placement of the implants is done near the posterior edge of the hard palate. If the patient has a long, floppy, soft palate and uvula, there may be a lower likelihood of successful reduction in subjective snoring. Multiple implants can be placed, with additional implants added up to a total of 5, in some cases. Some relapse after 12 months was common in many studies, and no significant reduction in obstructive sleep apnea has been shown with any consistency.
There is a small increased risk of infection after insertion of foreign material in the palate tissue. If this occurs, the implant should be removed and replaced with another implant. Although this sounds like a negative consequence, infection actually leads to scarring, which helps decrease the vibrations of the palate. The implant procedure results in less tissue inflammation and therefore the procedure does not hurt as much or for as long as following radio-frequency treatments.
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