Snoring surgery: Which one is best for you?

Introduction

Snoring is a significant social problem that is commonly managed by the otolaryngologist. Approximately 20% of all adults--including nearly 50% of those over 60 years of age--are chronic snorers. [1] Snoring is the hallmark symptom of a spectrum of sleep-related breathing disorders collectively termed sleep disordered breathing. The patho-physiologic cause of sleep disordered breathing is sleep-induced airway obstruction. Minimal airway obstruction causes primary, or simple, snoring. On the other extreme, complete airway obstruction causes obstructive sleep apnea syndrome (OSAS).

OSAS traditionally receives more attention than does snoring because of its well-documented influence on mortality. It is now evident that untreated snoring also has medical implications, especially in some snorers who do not have OSAS but who manifest excessive daytime sleepiness (EDS). [2] In these patients, an elevated degree of airway resistance causes sleep fragmentation and EDS, but without the obstructive episodes of OSAS. The identification of this group resulted in the recognition of a new syndrome, intermediate between primary snoring and OSAS, called upper airway resistance syndrome. [3] Patients with this syndrome benefit from appropriate treatment.

The proper management of snoring begins with conservative measures that decrease airway resistance. Conservative therapy includes exercise, weight loss, decreased alcohol consumption, smoking cessation, altered sleeping position, and dental or nasal appliances. Although these measures often provide some benefit, patients generally do not obtain sufficient relief from their snoring. For this reason, surgery is the preferred treatment. [4]

Because excessive snoring is so common, there is an incentive to find a simple, safe, effective, and economical surgical remedy. Many procedures were developed during the past 2 decades, but which procedure, if any, is preferable is controversial. No single procedure has been proven to have the ideals that justify its sole use over others.

Our purpose is to review the snoring literature and to provide an objective overview of the four primary types of procedures now in use. Although some snoring surgeries are also used to treat OSAS, our intent is not to assess their merits in OSAS. OSAS is mentioned only when clinical issues make it relevant.

Although we primarily address palatal procedures, the airway obstruction that produces snoring can occur at several sites. The anatomic areas most often implicated in snoring are the retropalatal pharynx and retrolingual pharynx. [5] Several surgical procedures are available to correct each type of snoring, but the retrolingual procedures are more invasive and complicated than the palatal procedures. Nasal surgeries, such as septoplasty and inferior turbinate resection, rarely provide relief from snoring when used alone. [6] They are best used as an adjunct to more definitive surgical procedures. For these reasons, most patients who desire surgical treatment are initially offered a palatal procedure.

Several surgical procedures performed to treat retropalatal snoring are common, while others are more novel. Many procedures have similarities with others. For this review, we placed each procedure into one of four general categories: uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, palatal stiffening operations, and radiofrequency ablation (table). Based on our clinical experience with all of these procedures, we describe the advantages and limitations of each, and we offer clinical pearls that pertain to each technique.

Uvulopalatopharyngoplasty

In 1964, the Japanese surgeon Ikematsu described uvulopalatopharyngoplasty (UPPP), the first surgical treatment for snoring. [7] In 1981, Fujita introduced the procedure, with slight modifications, to the United States for the treatment of OSAS. [8] He soon realized that UPPP reduced snoring in his OSAS patients. Later, with more data, Fujita recommended UPPP to treat snoring in addition to OSAS. [9] The new procedure quickly became the gold standard.

In the technique described by Fujita, the patient undergoes a tonsillectomy, which is followed by a partial removal of the soft palate, uvula, and pharyngeal arches (figure 1) Finally, the mucosal edges are approximated with sutures. The procedure is performed under general anesthesia. The intended effect is to lessen snoring by allowing more room for airflow and by reducing vibratory tissue.

Early results indicated that UPPP was 75 to 100% effective in eliminating or significantly reducing snoring. [10-13] This was most encouraging, but as these patients were followed, it became apparent that the long-term success rates were not as good, ranging from 46 to 73%. [14-16] Koay et al specifically addressed this change in patient satisfaction and found that 13% of patients who had "successful" outcomes within the first postoperative year subsequently developed a recurrence of their snoring. [17]

The reasons for this decline in efficacy are not entirely known. The decrease in long-term success rates might represent a true increase in the incidence of snoring, or it might merely be a reflection of inexact measurements. Unfortunately, there is no standard way to measure intensity of a patient's snoring. Nearly all researchers rely on the subjective assessment of the patient's bed partner, and they use one of several scales to quantify the intensity of snoring. Attempts to objectively quantify intensity have met with only limited success. [18-19] For now, snoring is "in the ears of the beholder," because its capacity to irritate involves more than just decibels. [20]

Another problem is that there is little agreement on what constitutes a successful outcome. Some authors define success as "improved to absent snoring," while others call it "absent or markedly reduced snoring." Using the former definition will interject bias into a study toward a better outcome, as is evident in the literature.

Until these issues are resolved, it will remain difficult to quantify the true outcome of UPPP or any other snoring procedure. Nonetheless, in the largest long-term UPPP study to date, only 46% of patients said that they had stopped snoring or that their snoring was markedly improved (i.e., their bed partner was infrequently awakened). [15] There is little doubt that many UPPP patients do not obtain adequate relief of their snoring.

In addition to relieving snoring, UPPP alleviates EDS. In one long-term study of 51 patients who initially complained of EDS, 73% later said that their EDS had been completely or markedly alleviated. [16]

Few studies have specifically addressed UPPP's complications. Of the four major studies that did, all included patients with OSAS, and only three estimated the prevalence of any complications. Of these three studies, the two largest were retrospective, while the other was a smaller prospective series. The most serious perioperative complication was a 2 to 11% incidence of postoperative airway obstruction that resulted in an approximately 1% perioperative mortality. [21-23] One group reported a 5% incidence of difficult intubation, but they correlated that incidence to the severity of OSAS. [21] Postoperative bleeding serious enough to require a return to the operating room occurred in 2 to 5% of cases. [21-23]

Clinical experience indicates that UPPP is often complicated by severe postoperative pain. Few studies have attempted to quantify this. In one series, 86% of patients were satisfied with the outcome of their procedure, but in retrospect, because of the pain, only 60% said they would undergo the same treatment. [21]

The most common long-term complications are velopharyngeal incompetence (VPI) and palatal dryness. Temporary postoperative VPI occurs in most patients, and studies have reported that 10 to 24% of patients continued to complain of intermittent nasopharyngeal regurgitation 1 year after surgery. [22,23] In the same studies, up to 31% of patients complained of persistent palatal dryness. [22,23] Less frequent long-term complications include nasopharyngeal stenosis, long-term voice changes, and a partial loss of taste. [22-24]

In addition to all its limitations, UPPP is expensive. Costs vary widely among institutions, but the procedure, the anesthesia, and 1 night of postoperative monitoring in an intensive care unit can cost in excess of $10,600. [6]

Laser-assisted uvulopalatoplasty

The limitations of UPPP created a demand for a more effective, safe, economical, and comfortable alternative. In 1986, the French surgeon Kamami used a [CO.sub.2] laser for a procedure initially called laser vaporization of the palatopharynx. It was similar to the standard UPPP except that the tonsils were not removed, and it was performed in several stages under local anesthesia. Kamami's initial results, published in 1990, were encouraging, as the short-term success rate was 97%. [25] Coleman introduced the procedure to the U.S. in 1992, but by then it had been modified and was called the laser-assisted uvulopalatoplasty (LAUP). [26]

The most popular LAUP technique was described by Krespi and Keidar in 1994. [27] A [CO.sub.2] laser with a special backstop attachment is used to make vertical through-and-through incisions on both sides of the uvula. These incisions form trenches that extend 1 to 2 cm from the free edge of the velum. The uvula is then shortened significantly (figure 2). The entire procedure is performed under local anesthesia and is repeated in 4 to 6 weeks as necessary.

Short-term data indicated that LAUP either eliminated or significantly decreased snoring in 70 to 97% of patients. [25,28-33] Two clinical trials directly compared LAUP with UPPP, and both failed to show any significant difference in short-term efficacy between the two procedures. [31,34] LAUP also appeared to alleviate EDS, as 72% of patients who had EDS reported either a diminution or elimination of their symptoms. [28]

As happened with UPPP, it was feared that these optimistic short-term results would deteriorate with longer Follow-up. Kamami reported in his own series of 741 patients that "after several months ...snoring had reappeared in a few cases, but [it was] much less disturbing than before." [28] The first research to specifically address this issue indicated that the efficacy of LAUP did decrease over time. [35] At 18 to 24 months after surgery, only 55% of patients reported that their bed partner was satisfied with the outcome. As with the UPPP data, LAUP studies are difficult to interpret because of nonstandardized measurements and subjective reporting.

LAUP is less invasive than UPPP. LAUP requires less palatal resection, and it does not remove the tonsils. Unlike UPPP, it is performed under local anesthesia. These differences should result in fewer postoperative complications, especially bleeding and airway obstruction. The less-extensive palatal resection should also mean fewer long-term complications such as VPI and voice changes. Clinical experience confirms this to be true. In the largest study of LAUP complications to date, Walker and Gopalsami prospectively followed 275 patients who had undergone 754 procedures. [36] They found that 1.3% of patients experienced postoperative hemorrhage that required medical treatment, 0.5% had a local infection, 0.5% had temporary VPI, and 0.3% had a temporary loss of taste. There were no cases of airway compromise or death and no long-term VPI, nasopharyngeal stenosis, or voice changes. Smaller studies reported similar complication rates, although the incidence of temporary VPI has been reported to be as high as 3%. [33] There have been no reports of death or permanent nasopharyngeal stenosis secondary to LAUP.

Although LAUP is generally associated with fewer complications than UPPP, postoperative pain is the one exception. Both of the clinical trials that directly compared LAUP with UPPP showed no significant difference in postoperative pain between the two procedures. [31,34] Postoperative pain peaked anywhere from 3 to 9 days after surgery, and it usually resolved within 2 weeks of surgery. [32,35] Severe pain from LAUP negatively affects patient compliance. [32,33] In one report, 77% of patients who abandoned their therapy early cited severe pain as the most important reason. [32] Also, unlike UPPP patients, who undergo the procedure only once, LAUP patients must endure the postoperative pain several times. The number of procedures needed varies, but most patients require two to four sessions. [25,26,28,29,32] Another disadvantage is that LAUP is difficult to perform on patients who have a strong gag reflex.

Enthusiasm for LAUP rapidly proliferated throughout the U.S., and as a result, the procedure started being used to treat OSAS, even though there were concerns that there were not enough data to support its use for this condition. Further reports on the indications for LAUP created confusion and controversy. In 1996, Lauretano et al reported that OSAS was actually worse in some patients following LAUP. [37] Research also raised a theoretical concern that although LAUP can eliminate snoring, it might exacerbate the underlying pathophysiology of OSAS, even in patients with only primary snoring. [38] LAUP could alleviate a patient's symptoms, but it could also lead to worse obstructive disease.

This concern was confounded by evidence that showed that untreated OSAS is a progressive disease. [39] Many patients who developed further airway obstruction after LAUP might have been even worse if they had not undergone the surgery. Currently, the American Sleep Disorders Association does not recommend LAUP for the treatment of either snoring or OSAS. If LAUP is desired, the association recommends that the preoperative evaluation of each patient include an objective measurement of respiration during sleep to rule out OSAS. [40]

Near the time Kamami pioneered LAUP, the Swedish surgeon Carenfelt described a similar technique. [41] To perform his procedure, which he called laser uvulopalatoplasty (LUPP), Carenfelt used a [CO.sub.2] laser to resect the palatal tissue, much like UPPP does. LUPP was performed in one stage just like UPPP, but it required only local anesthesia. The short-term results of LUPP were similar to those of UPPP, [41,42] but it never became as widespread as UPPP and the staged laser techniques.

Other variations of the LAUP technique include Nd:YAG LAUP, cautery-assisted uvulopalatoplasty, and cold-steel uvulopalatoplasty. Each of these techniques uses different cutting instruments to perform essentially the same procedure. Data evaluating these procedures are limited, but so far they indicate that these variations pro-duce results similar to those of the standard LAUP. [43-46]

The disadvantage of LAUP is that the tonsils are not removed. Krespi and Ling described a laser-assisted serial tonsillectomy that can be performed concurrently with LAUP, but their procedure is not in widespread use. [47] The more common approach is to perform UPPP on patients who have tonsillar hypertrophy and perform LAUP on those who do not. [31]

Overall, the results of LAUP are comparable with those of UPPP, but they can be obtained at a fraction of the cost. [6] A national newspaper recently estimated that the cost of LAUP is only $1,500 to $2,000. [48] This figure does not include the additional cost of a sleep study.

Palatal stiffening operations

Concern over the morbidity caused by UPPP and LAUP led to a search for a technique that is simple and minimally invasive and that does not interfere with normal velopharyngeal function. In 1993, Ellis et al used a mechanical model to demonstrate that stiffening the soft palate, rather than shortening it, can reduce the "palatal flutter" of snoring. [49] They proposed inducing scar formation by using an Nd:YAG laser to remove a longitudinal strip of palatal mucosa, while leaving the velum and uvula intact. The short-term results of their series of 16 laser palatoplasty patients were similar to those of UPPP studies, but complications were only minimal.

Ingrains et al used a laser to perform a palatoplasty similar to Ellis's technique except that they used a [CO.sub.2] laser and amputated the uvula. [50] Their results were comparable. Clarke et al adopted the palatal stiffening concept, but abandoned lasers in favor of electrocautery. [34] In their randomized, controlled trial on 62 patients, they showed that there were no significant differences in 6-month efficacy between cautery palatoplasty, laser palatoplasty, and UPPP. Cautery palatoplasty and laser palatoplasty caused significantly less short-term VPI. Postoperative pain was similar in all three groups.

Another development was the cautery-assisted palatal stiffening operation (CAPSO), in which the surgeon uses electrocautery to remove a longitudinal strip of mucosa along the soft palate and the anterior uvula (figure 3). A recent series of 206 CAPSO patients showed a 92% short-term success rate (defined as a patient report that snoring is no longer a problem) and a 77% success rate at 12 months. [51] There were no intraoperative complications. Postoperative complications included bleeding (1%), temporary VPI ([less than]1%), and temporary xerostomia or taste changes (1%). There was no evidence of nasopharyngeal stenosis, wound infection, or voice changes. Odynophagia was notable during postoperative days 3 through 10, with peak intensity on days 5 to 7. The pain had usually resolved by postsurgical day 12.

Palatal stiffening procedures have advantages over their predecessors. The data now available show that their short-term efficacy is similar to those of UPPP and LAUP. The minimal invasiveness of these procedures should mean fewer complications than with the previous procedures, a belief that is supported by the limited data previously described.

Palatal stiffening procedures are also more convenient and more economical than their predecessors. Each palatal stiffening is performed during a single outpatient visit under local anesthesia. An added advantage of the electrocautery procedures is that they do not require expensive and cumbersome laser equipment. Costs vary among institutions, but our experience shows that CAPSO costs about $150, which is about 10 times less expensive than complete treatment of snoring with LAUP and more than 70 times more economical than UPPP with overnight intensive care.

Radiofrequency ablation

Recently, Powell et al used a custom-fabricated electrode to deliver radiofrequency energy to the soft palate (figure 4). [52] The primary objective of their experiment was to determine the safety of the procedure--called radiofrequency ablation (RFA) or somnoplasty (Somnus Medical Technologies Inc.; Sunnyvale, Calif.)--because radiofrequency energy is rarely used in the upper airway. In their prospective, nonrandomized study, 16 patients reported a mean 77% decrease in snoring after three or four procedures. There were no major complications. The most common minor complication was erosion of the palatal surface mucosa 2 to 4 days after treatment. Complications reported in another study of 18 patients included two cases of uvular sloughing and one case of submucosal fistula. [53]

The advantage that RFA has over UPPP and LAUP is that it is minimally invasive, which implies fewer complications. It induces palatal stiffening by scarring palatal muscle, but it normally leaves the palatal mucosa unaffected. This should make RFA significantly less painful than any other snoring procedure.

Like LAUP and the palatal stiffening procedures, RFA is performed under local anesthesia. Unfortunately, unlike the palatal stiffening procedures, RFA requires the patient to undergo several treatment sessions. Care must be taken to insert the needle directly into the palatal muscle, because superficial placement leads to mucosal sloughing. Also, because the needle is extended into the palate without direct visualization, the needle might be placed inadvertently through the palate into the nasopharynx. RFA requires expensive equipment, including a radiofrequency generator and disposable handpieces. Overall, a complete RFA of the soft palate costs around $2,500. [54]

The applications of RFA are expanding. We find it useful for turbinate and base of the tongue ablation for treating snoring and OSAS, [55,56] although we have experienced complications, including tongue base abscesses. RFA has a distinct advantage over other snoring procedures because it is the only outpatient snoring procedure that addresses snoring from several anatomic sites. RFA is promising, but until it is compared directly with other snoring treatments, its advantages will remain unproven.

Discussion

The otolaryngologist should customize palatal snoring surgery in accordance with the patient's anatomy, the patient's social and financial concerns, and with his or her own practice parameters. Our current clinical practice uses all four major surgical techniques to various degrees. Each procedure can have a place in the clinical practice of today's otolaryngologist. UPPP has advantages for the snorer with a redundant posterior pharyngeal wall or large tonsils. [29] LAUP is attractive for compliant patients with large posterior tonsillar pillars when laser equipment is readily available. RFA should be considered for compliant patients when a radiofrequency generator and disposable handpieces are available. Pain is minimized when mucosal ulceration does not occur. RFA is also under investigation for use in newer applications, including turbinate and tongue base ablation for snoring and OSAS. The palatal stiffening operations are performed during a single office procedure under local anesthesia, and the palatal procedures that use electrocautery are performed with minimal expense.

We have not mentioned every procedure that is used to treat palatal snoring. Uvulectomy has been attempted, but its short-term results were poorer than those of other procedures. [57] In addition, newer procedures are under investigation, including ones that induce palatal stiffening by injecting sclerosing agents into palatal tissue. [51]

It should be emphasized that the procedures discussed in this article address palatal snoring exclusively, and they make up only one component of the management of the snoring patient. All patients who complain of snoring should attempt conservative therapy first because it is simple, safe, and part of a healthy lifestyle. Surgery for snoring is rationally performed in a stepwise manner, usually beginning with procedures that address palatal snoring and, if necessary, progressing to procedures that correct other levels of airway obstruction. [6]

All procedures are discussed here in the context of treating snoring, not OSAS. It is wise to ensure that any snoring patient does not have OSAS before the surgeon attempts any surgical procedure. Every patient should have some type of objective measurement of sleep respiration. Just how extensive this screening should be is a controversial matter, so the decision is generally left to the clinical judgment of the otolaryngologist.

A number of techniques have been described to improve patient selection for snoring surgeries. Objective measurements such as the Muller maneuver and sleep nasoendoscopy attempt to identify palatal snorers, but the reliability of each of these procedures has been brought into question. [58,59] More recently, acoustic analysis of oronasal respiration (SNAP testing) has shown promise as a technique to identify the low frequency of velum-like snoring. [60]

Studies remain difficult to interpret because of the lack of standardized methods to report snoring outcomes. Several promising measurement techniques are now used. The subjective recording of surgery outcomes on a standardized visual analog scale is the most prominent of the new techniques, and its use will lessen some of the confusion.

Although we categorized each snoring procedure by the specific technique and modality, all of these procedures have important similarities. The traditional emphasis (especially with UPPP) is on increasing pharyngeal airspace. However, the clinical effect of each procedure might be primarily the result of palatal scarring. If palatal scarring is the common denominator of all snoring surgeries, it is logical to use techniques that induce as much scarring as possible without unnecessarily disturbing velopalatal function. CAPSO and RFA are ideal in this situation.

From the Otolaryngology-Head and Neck Surgery Service, Walter Reed Army Medical Center, Washington, D.C.

Reprint requests: Eric A. Mair, MD, Otolaryngology-Head and Neck Surgery Service, Walter Reed Army Medical Center, Washington, DC 20307. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the United States government.

Abstract

Excessive snoring is a common problem that is frequently treated surgically. In the early 1980s, uvulopalatopharyngoplasty was introduced to the United States as the first surgical treatment for excessive snoring. It remains in common use, but its limitations created an incentive to develop a procedure that is as effective, but safer and more economical. Several other surgical procedures for snoring were developed, including laser-assisted uvulopalatoplasty, palatal stiffening operations, and radiofrequency ablation. Each of these procedures has its own advantages and limitations; which procedure is the best treatment for excessive snoring is controversial. We present our experience with each of these procedures, along with a thorough review of the literature, to help the otolaryngologist determine which is the best snoring surgery for the individual patient.

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              Characteristics of different snoring surgeries
Procedure     UPPP [*]         LAUP [+]      CAPSO [++]    RFA [ss]
Efficacy
  Short-term  ++++             ++++          ++++          +++
  Long-term   ++               ++            Unknown       Unknown
Anesthesia    General          Looal         Local         Local
No. sessions  Single           Multiple      Single        Multiple
Pain          ++++             +++           +++           +
Cost          $$$$             $$            $             $$$
Anatomic site Palatopharynx    Palatopharynx Palatopharynx Palatopharynx
              Palatine tonsils                             Tongue base
                                                           Turbinates
(*.)Uvulopalatopharyngoplasty.
(+.)Laser-assisted uvulopalatoplasty.
(++.)Cautery-assisted palatal stiffening operation.
(ss.)Radiofrequency ablation.