Snoring and Obstructive sleep apnea (OSA) surgery; what is the role of Sleep surgery?

Misconceptions:

1.       Snoring is normal and no need to be treated

2.       Snoring is due to adenoid enlargement only

3.       Snoring is only treated with just one surgery that is Uvulopalatopharyngoplasty (UPPP)

4.       OSA only occurs in obese patients

5.       Severe OSA is only treated with CPAP

What is Snoring and OSA?

Snoring is a sound generated by vibration of the soft tissues of the upper airways during sleep. It occurs when air travels through a narrow passage generating that sound.

There are 3 types of snoring:

1.       Normal snoring: that happens due to exhaustion of long travels or change of bed and that doesn’t happen every night.

2.       Social (habitual) snoring: that happens every night and that can affect the sleep of the bed partner due to that loud irregular noise and that needs treatment by medicines or minimally invasive procedures.

3.       Medical snoring that is so loud and associated with OSA.

Snoring is children is mainly due to adenoid enlargement but it is not the only cause so any lesion in the upper airways (from nose down to larynx) causing narrowing of the airflow will cause snoring and OSA.

OSA is complete obstruction (Not only narrowing) of the upper airways for 10 seconds during sleep. During which blood oxygen level drops and patient has to wake up to restore some muscle tone and open up the obstructed upper airways. That happens more than one time during each hour of sleep and results in bad sleep quality and morning headache and daytime sleepiness. In more severe degrees, that change in blood oxygen level during sleep can result in hypertension, diabetes mellitus or even stroke. OSA is called “the silent killer” as some patients are not aware of that condition and don’t know how to be diagnosed.

Historically, snoring and OSA were only treated by one surgery called UPPP (in which part of the soft palate and tonsils were removed to widen the upper airways) but recent meta-analysis studies showed that it was effective in only 40% of cases, so now it is obsolete.

What is the role of sleep surgeon?

To properly diagnose the sleep related breathing disorder and identify exactly the cause and manage it properly. Now all patients who are complaining of snoring or sleep related problems should do the following:

1.       Proper ENT examination to search for the obstructive lesion; starting from the nose, nasopharynx, oropharynx, hypopharynx and even larynx.

1.       Overnight sleep testing; to identify if the problem is that obstructive lesion or there is associated central or lung problem causing that airway obstruction during sleep. Sleep test is the only way to properly understand what is going on during the night.

Drug induced sleep endoscopy (DISE); to examine the upper airway from the nose to the larynx while the patient is asleep and snoring and OSA are happening. Some obstructive lesions (especially of the larynx) are not evident during awake examination and need to be seen during the sleep. Usually patients cannot tolerate endoscopy while asleep and that may cause their awakening so we induce sleep by certain IV drugs and put EEG to monitor brain activity and make sure we are at the correct stage of sleep required for examination.

After that all, we can have clear diagnosis of what and where is the problem during sleep to avoid unnecessary surgeries with poor outcomes. Although CPAP is the gold standard therapeutic option for OSA, only 50% of patients accept to use it and are compliant to its use. That is why our role is to provide surgical substitute for those non-compliant patients.

Surgical interventions are so many and start from minimally invasive procedures in mild cases to more invasive ones to widen the nose, pharynx and larynx (multilevel surgery) in moderate cases to more aggressive bone surgeries widening the airways in severe cases.

Nowadays, more advances in technology helped introduction of robotic surgeries to widen the airways from the mouth (Trans-oral robotic surgery) , and improving the muscle tone of the upper airways muscles by implanting stimulator the main nerve supplying the tongue and pharynx (hypoglossal nerve stimulation surgery).

When you should suspect that you may have OSA?

If your answer is YES in 5 or more questions, you need to visit us