Snoring and Sleep Apnea Surgery

Snoring

A harsh, loud sound produced during sleep by vibration of the soft palate, uvula and surrounding soft tissues.

Sleep Apnea

A pause in breathing lasting 10 seconds or longer.

Hypopnea

A 50% reduction in airflow over the same period, accompanied by a drop in blood oxygen level (desaturation) or arousal.

Snoring

It usually occurs when breathing in. In some people, snoring may also occur with the mouth closed. Snoring is a sign of increased resistance in the upper airway. When the resistance increases further, it is seen together with sleep apnea.

People who snore often have narrowing of the upper airway, obesity, nasal congestion, facial and jaw disproportions, hypothyroidism, acromegaly, or enlarged tonsils and adenoids. Snoring without sleep apnea is called “primary snoring” or “simple snoring.” People who snore are mostly not bothered by it themselves. Usually it is their bed partner or household members who complain (a social problem). While snoring is often heard only in the room where the person sleeps, it can sometimes be loud enough to be heard throughout the house and can even lead to partners sleeping in separate beds.

Causes of snoring

• An elongated, sagging soft palate and uvula,
• Large tonsils and adenoids (especially in children),
• Swelling of the turbinates and mucosa (especially in allergies),
• Anatomical problems in the nose: deviated septum, nasal valve insufficiency, turbinate hypertrophy, polyps, etc.,
• Obesity,
• Alcohol, sedatives and tranquilizers.

Sleep apnea

This is a pause in breathing lasting 10 seconds or longer during sleep. During this time, the blood oxygen level drops and sleep is interrupted. Sleep has different stages. The stage in which we rest the most is deep sleep, and sleep apneas occur most often in this stage. When a person has an apnea, they shift from deep sleep to light sleep; they often do not wake up fully and are unaware of the apnea. As deep sleep time shortens with repeated apneas, they wake up unrested and experience daytime sleepiness. Because the blood oxygen level falls during apnea, many vital organs, primarily the brain and heart, are deprived of oxygen during the apnea period, and as a result many risks arise, including sudden death.

Obstructive sleep apnea syndrome (OSAS)

Obstructive sleep apnea syndrome (OSAS) is caused by blockage or narrowing of the upper airways during sleep. In OSAS, the person tries to breathe but cannot because the upper airway is blocked. Conditions that cause obstruction or narrowing of the upper airway are the causative factors in OSAS. The upper airway starts at the nose and continues through the nasopharynx, soft palate and base of the tongue down to the larynx. Therefore, narrowing or blockage in one or more of these areas can cause OSAS.

In most cases, the obstruction is not at a single level. It occurs as nose + soft palate, soft palate + base of the tongue, or nose + soft palate + base of the tongue. For this reason, surgery on the nose alone is not enough to treat sleep apnea.

Sleep apnea can cause hypertension, ischemic heart disease, heart attack, heart rhythm disorders, risk of stroke, headache, pulmonary hypertension, right heart failure, a predisposition to diabetes through the development of insulin resistance, low sex drive, prostate enlargement, growth delays in children due to reduced growth hormone, traffic and workplace accidents, and marital problems.

Patients with sleep apnea have nighttime and daytime symptoms. The person is unaware of most of the nighttime symptoms. Nighttime symptoms include snoring, pauses in breathing during sleep, excessive movement during sleep, disrupted sleep at night, reflux, frequent urination at night, urinary incontinence and night sweats. Daytime symptoms include sleepiness, fatigue, forgetfulness, inattention and poor concentration, personality changes, depression and anxiety disorders, sexual problems such as low libido, lack of sexual desire and sexual dysfunction, morning headaches, dry mouth and sore throat.

Sleep apnea is diagnosed with a sleep study called polysomnography (PSG). For the sleep study, the person stays overnight in a sleep laboratory. Sensors are attached to certain areas of the body to record the person's breathing through the nose and mouth during sleep; how many times and for how long they stop breathing; in which stages of sleep the apneas occur; whether the apneas are central or obstructive (OSAS); changes in blood oxygen levels; heart rate and rhythm; chest and abdominal movements; and brain waves and changes in sleep stages. Based on the results, the severity of sleep apnea is graded as mild, moderate or severe.

A sleep study should be performed in patients who snore, have witnessed apneas and have daytime symptoms.

The sleep study is performed by PSG technicians, and the results are reported by the pulmonologist, ENT specialist or neurologist in charge of the sleep laboratory.

Every patient found to have sleep apnea in a sleep study should undergo an ENT examination. In this examination, a detailed endoscopic examination is performed starting from the nose and including the nasopharynx, base of the tongue and larynx. The size of the tongue and tongue base, the position and size of the soft palate and uvula, and the tonsils are also evaluated. The ENT examination can identify blockages and narrowings in the upper airway.

Patients with snoring and apnea should exercise regularly, avoid eating before going to bed, quit alcohol and smoking, stop taking sleeping pills, lose weight and choose a suitable sleeping position.

Surgical treatment of snoring and apnea

Surgical treatment is recommended for snoring, for mild to moderate sleep apnea, or for patients who cannot adapt to PAP therapy. The aim is to prevent obstruction during breathing by widening the anatomically narrowed area or areas of the upper airway. The narrowing may be in one or more of the following regions: the nose, nasopharynx, soft palate and uvula, base of the tongue or larynx. Accordingly, surgery may be needed on one or more of these areas.

Nasal Surgeries

Septoplasty (deviated septum surgery), turbinate reduction, nasal valve surgery, and endoscopic sinus surgery (for polyps or nasal masses). Nasal surgery alone improves snoring in 50% of cases and mild sleep apnea in 10% of cases.

Surgeries of the Nasopharynx

Removal of the adenoids and surgery for nasopharyngeal masses.

Palate Surgeries

Many techniques are used, such as uvulopalatopharyngoplasty (UPPP), lateral pharyngoplasty, transpalatal advancement, anterior palatoplasty and expansion sphincter pharyngoplasty. Recently, the anterior palatoplasty technique has become very popular. It is also used successfully in our clinic for snoring and mild to moderate apnea.

Tongue Base Surgeries

Methods such as tongue base tissue reduction, tongue base suspension and hyoid suspension have been described, but they have not become widespread because of prolonged pain and eating problems, high complication rates and low effectiveness in the medium to long term.

Maxillomandibular advancement

This is surgery to move the upper and lower jaws forward. It has the highest success rate of all the operations listed above. Its effectiveness in treating sleep apnea reaches 90% in selected patients. However, it is rarely performed because, compared with the others, it has a longer recovery time, a higher complication rate and causes a permanent change in facial appearance.