Science, Sleep Apnea, Solutions

Surgery for Snoring and Sleep Apnea

Surgery is perhaps the most drastic snoring remedy available and has the potential to be very effective for some people. There are a number of surgical interventions to reduce snoring and sleep apnea.

In this article, we summarise the different types of surgery for snoring and sleep apnea, as well as exploring some of the important considerations to be made before opting for surgery.

Some important considerations

Surgery should be a last resort

Surgical intervention should only be considered if other methods you have tried have failed.

Surgery is invasive and sometimes irreversible, so careful consideration should be given as to whether alternatives have been pursued to their full capacity.

Though it will usually be discussed in any consultation prior to surgery, some of the most effective methods of treating snoring are non-surgical and always worth mentioning. These include:

• Weight loss
• Sleeping on your side
• Addressing underlying allergies
• Breathing through your nose when you sleep
• Stopping smoking and reducing alcohol consumption
• Changing your evening eating habits

Surgery types vary and what is most suitable depends on YOU

There are several different types of surgery that can reduce snoring. Like non-surgical snoring remedies, there is no one solution that will work for everybody.

The most effective type of surgery depends on your snoring and what is causing it in the first place.

Your suitability will need to be assessed with a physical examination

For surgery to be effective to treat snoring, there must be a clear physical cause of snoring. This means you’ll need to undergo a thorough examination by an ENT (ear, nose and throat) specialist to identify the source of the snoring.

Initial examinations will include basic observations of your nose, tongue and throat. The procedure is also likely to involve flexible endoscopy.

Here, a flexible tube with a fibre optic camera is inserted into the nose and down the back of the throat to look for structural abnormalities.

Whilst this tube is in place, the examiner may ask you to recreate a snoring sound to help identify the tissue that is producing the noise.

You may have to undergo a sleep study first

It is important to distinguish between primary snoring and obstructive sleep apnea. This is because certain types of surgery are not recommended for obstructive sleep apnea (OSA) sufferers.

For that reason, if OSA cannot be ruled out after a physical examination, you may have to undergo a sleep study. This can be done either in a specialist sleep clinic or at home.

 

The benefits may not be permanent

The body has a remarkable way of adapting to change, and unfortunately this isn’t always a good thing.

Snoring surgery that addresses soft tissue works by causing intentional scarring to certain parts of the airway to stiffen them. Your body will automatically work to heal these scars, therefore whilst the snoring is reduced in the short term, you may find that it returns in the long term.

You could experience side effects

Whilst the side effect profile depends on the type of surgery you have, surgery will always involve breaking tissue which carries risks.

It is common for patients to experience some mild pain after surgical interventions.

Availability varies depending on where you live

Every country’s health system is different, and for that reason what is recommended, available and suitable in one location may not be so in another.

For example, pillar implants are considered suitable to treat mild-moderate obstructive sleep apnea in the USA but not in the UK [1].

The healthcare system in your location may also affect whether or not you are eligible for snoring surgery. Because snoring is usually considered a trivial condition (though those that live with it would argue otherwise), state funded medical systems are reluctant to fund snoring surgery. Further, snoring surgeries may not be covered by certain insurance policies.

The different types of surgery

There are three main categories of surgery that can help to directly reduce snoring:

1. Soft Tissue surgery.
2. Maxillofacial surgery.
3. Neural stimulation.

1. Soft tissue surgery

The least invasive option, this involves making changes to the soft noisemakers themselves.

Soft tissue surgery aims to remove or stiffen the flappy parts of the airway which vibrate and cause the snoring noise.

Other soft tissue procedures involve making changes to structures in the nose that can cause “downstream” snoring via nasal blockage.

Most types of soft tissue surgery are not recommended for OSA sufferers, though this does vary.

Usually, these procedures can be performed in an outpatient clinic under local anaesthetic (i.e. you are awake but cannot feel pain in that region).

Uvulopalatopharyngoplasty

Also known as UPPP or UP3, this surgery aims to open the upper airway by removing tissue from the uvula, soft palate and pharynx. If they are still present, it can also involve removal of the tonsils and adenoids (the latter usually disappearing in adolescence).

It is the most invasive form of soft palate surgery and must therefore be performed under general anaesthetic (i.e. you are unconscious).

Whilst UPPP is one of the few soft tissue procedures recommended for OSA, it is performed less often than it used to be. This is because less invasive techniques with lower side effect profiles have emerged. It has also fallen out of favour because UPPP can reduce the effectiveness of CPAP.

Laser-assisted uvulopalatoplasty

Using a similar principle to UPPP, as the name suggests, laser-assisted uvulopalatoplasty (LAUP) uses carbon dioxide lasers to stiffen and remove tissue from the soft palate and uvula to widen the airway [2].

Because of the enhanced precision of lasers, it is considered a safer alternative to UPPP.

This procedure is usually done under local anaesthetic in a clinic and is done over three to four separate sessions.

Despite it being said that LAUP is suitable to treat mild to moderate OSA, studies have not demonstrated consistent improvements for these patients [3].

Radio frequency ablation

Also known as “somnoplasty”, this type of snoring surgery uses radiofrequency energy to generate heat for creating controlled lesions in soft tissue. The basis here is that the lesions become scarred and retract, reducing the amount of flappy tissue and stiffening what remains.

This can be performed on different parts of the airway depending on where the blockage is, including the turbinates of the nose (folds of tissue in the nasal cavities), the soft palate and the base of the tongue.

A minimally invasive technique, it is performed under local anaesthetic in an outpatient setting [2].

Injection snoreplasty

In this snoring surgery, no tissue is removed. Instead, sodium tetradecyl sulphate, a chemical used to treat varicose veins, is injected into the soft palate in order to scar it.

Whilst there are advantages here in that it is minimally invasive and doesn’t involve the removal of tissue, this is a fringe therapy and won’t be recommended by many clinicians. This is because the evidence to support its effectiveness is somewhat lacking, with only a few studies with small sample sizes.

Pillar procedure

This popular outpatient procedure performed under local anaesthetic involves inserting three or four small polyester implants into the soft palate to increase its stiffness and reduce vibration.

The pillar procedure has shown to reduce snoring for many patients. However, studies indicate that their effectiveness starts to decline after they have been in place for more than one year [4].

Septoplasty

A slightly different procedure, this surgery involves straightening the nasal septum – the cartilage which separates the two nasal cavities.

A deviated septum is where this cartilage is bent. It is therefore more difficult to breathe through your nose. This causes you to make a switch to mouth breathing which is known to increase the risk of snoring.

A septoplasty is usually performed in an outpatient setting and has very few/rare complications and side effects.

2. Maxillofacial surgery

Maxillofacial surgery makes structural changes to the bones of the face, jaws and neck. This aims to increase the space in the upper airway.

They are quite serious procedures which need to be done under general anaesthetic and will involve a hospital stay.

hese procedures are further reaching that soft tissue surgery. As a result, maxillofacial surgery can have life-changing benefits for patients with severe obstructive sleep apnea.

Maxilla/Mandible Advancement

This simply refers to repositioning the bones of the jaw. It usually involves moving the lower jaw (mandible) forward. This is done by cutting the bone and holding it in a more advanced position with metal plates and screws.

A receded lower jaw reduces the airway space behind your tongue; moving it forward widens this space and makes obstruction less likely.

This surgery can be likened to a permanent version of what an anti-snoring mouthpiece is designed to do.

If necessary, surgery can also be performed to move both the upper (maxilla) and lower (mandible) jaws forward.

Whilst this surgical option is quite drastic and will involve a period of recovery, it is the only procedure that is considered curative for severe obstructive sleep apnea. In multiple published trials over the years, patients consistently show a decreased AHI and reduced sleepiness.

Because of the changes to the bones of the face, this surgery will often cause irreversible changes to your appearance (often, patients report, for the better).

Hyoid suspension

The hyoid bone rests in the upper part of your neck. It is the only bone in the body that doesn’t connect to any other bone (and is therefore referred to as a “floating bone”).

Anti-snoring surgery can be performed on the ligaments that hold the hyoid bone in place. This helps to move the base of the tongue forward to create more space in the airway.

3. Neural stimulation

This is an exciting, new type of surgery which involves electrical stimulation of the tongue muscles to keep the airway open. It is only ever performed on patients with obstructive sleep apnea.

The system usually consists of three small parts:

• An electrode wrapped around one of the key nerves that stimulates the tongue to move forward.
• A generator which creates the electrical impulse. This is implanted in the chest and can be switched off in the morning wirelessly via a remote.
• A sensor which helps to synchronise the neural stimulation with inward breaths. This is implanted in muscles of the ribs but isn’t always included.

To be considered for neural stimulation surgery, you’ll need a diagnosis of obstructive sleep apnea with an AHI of 20-50 (i.e. moderate to severe) [5].

It is usually recommended only if CPAP has failed. As this is an emerging therapy with restricted approval and a limited number of surgeons trained to perform it, it is not an option available everywhere.

Conclusion

Surgery can be a very effective solution for some snorers and sleep apnea sufferers. However, like all snoring remedies, it isn’t suitable for everybody.

For surgery to work, there needs to be a clear physical abnormality that can be corrected.

Surgery should be a last resort only when other techniques to manage your snoring or sleep apnea have failed.

This article aims to give you insight into all of the different types of surgery available: the established techniques, the emerging procedures and those falling out of favour. It is important to note that what may be offered for you will depend on your symptoms, snoring causes, anatomy and the medical facilities where you live.