Snoring and obstructive sleep apnoea (OSA) are common medical conditions that affect between 15-50% of the adult population worldwide.
Snoring, due to vibration of tissues in the throat, can be a symptom of partial upper airway obstruction. The partial obstruction can lead to complete airway obstruction – a medical condition called OSA. This obstruction can occur anywhere along the course of the upper airway and usually occurs in the nose, in the oral pharynx behind the soft palate or behind the base of the tongue. In Singapore, about 15 percent of adults have OSA.
OSA treatment should be started if the sufferer experiences excessive daytime sleepiness with altered daytime performance, moderate to severe OSA, decreased blood oxygen saturation level and cardiovascular complications.
The current first-line treatment of OSA is with Continuous Positive Airway Pressure (CPAP) which requires wearing a mask that conveys pressurised air to the patient’s airway during sleep.
However, not all patients are able to tolerate CPAP or are willing to try this form of treatment. In these patients, surgical treatment is indicated.
If a patient opts for surgery, the upper airway is examined with nasoendoscopy performed by an ENT specialist to look for areas that contribute to upper airway obstruction during sleep. Identification of these areas allows the surgery to be tailored for that particular patient’s problem.
Several options for surgery exist that are directed at obstructions that may occur at the level of the nasal airway, soft palate or base of tongue.
The area behind the soft palate is the most common site of obstruction that causes snoring and OSA. Hence, most treatments are directed at this area. Obstruction in this area can be caused by excessively bulky and floppy soft palate tissue or enlarged tonsils. Surgical treatment of this area would aim to reduce the bulkiness and floppiness of the soft palate or remove enlarged tonsils.
In the nose, normal structures called turbinates may be enlarged from allergic rhinitis causing airflow blockage. The septum that divides the nose into two sides may also be deviated to one side, resulting in reduced flow through that nostril.
Options to relieve nasal airway obstruction include reducing the size of the turbinates and straightening a deviated septum. An open nasal airway establishes normal breathing and minimises mouth breathing.
Mouth breathing in OSA individuals worsens the posterior airway by allowing the tongue to fall back. In addition, establishing an open nasal airway passage can improve CPAP comfort and compliance in those who wish to continue using CPAP.
The base of tongue and lingual tonsils (lymphatic tissues at the back of the tongue) may be enlarged, impeding airflow during sleep. Obstruction at this site can be treated by a variety of methods depending on severity. Options include reducing the size of the bulky tissue of the tongue and/or lingual tonsils or shifting the position of the base of tongue forwards to reduce obstruction.
Surgical procedures serve to remove or reposition tissues that partially or completely block the upper airway during sleep. These procedures have been used for years and clinical outcomes have verified their use.
Tracheostomy involves creating a hole in the trachea, directly bypassing the upper airway obstruction. It is used in people with refractory base of tongue obstruction and in the morbidly obese with medical conditions that contraindicate surgeries that are more extensive. Though the success rate is 100 percent, this option is usually not accepted by patients and with the introduction of CPAP, it is seldom used to treat OSA.
Nasal airway obstruction caused by septum deviation or enlarged turbinates can interfere with nasal breathing during sleep. Options to relieve nasal airway obstruction include reducing the size of the turbinates and straightening a deviated septum.
The turbinates can be reduced either by radiofrequency ablation performed under local anaesthesia in the clinic setting or by surgical reduction under general anaesthesia (turbinoplasty). Correction of a deviated septum and nasal valve reconstruction can also be used to improve nasal patency.
Abnormal structures at the palate level include large tonsils, redundant lateral pharyngeal mucosal, thick and long soft palate and enlarged posterior tonsillar pillar muscles and mucosal. All these contribute to a narrow airway at the palatal level.
Uvulopalatopharyngoplasty (UPPP) and many variations of it can be used. Most surgeons have shied away from the traditional UPPP in favour of modified techniques and surgical flaps (like uvulopalatal flap, extended uvulopalatal flap, lateral pharyngoplasty) as these have fewer complications, are less ablative and have a higher success rate.
In carefully selected patients with obstruction at the palate level, the success rate may be 50 to 60 percent but increases when combined with other procedures that address nasal and tongue base obstruction.
Hypopharyngeal and Base of Tongue Surgery
Compared to the nasal and oropharyngeal level, obstruction at the hypopharyngeal (base of tongue) level is a very complex issue as the large tongue base tissue collapses easily during sleep.
Obstruction at this level may be addressed by either increasing airway size to make more room for the tongue or reducing the tongue size. Both soft tissue techniques and skeletal work may be required. Soft tissue work involves removing the mid-portion of the tongue (median glossectomy, lingualplasty or volumetric reduction by radiofrequency). Transoral robotic surgery can be used to access this area.
Skeletal advancement techniques can increase the airway size and tension on the tongue so that even if the tongue falls back during sleep it does not obstruct the airway. This procedure includes inferior sagittal mandibular osteotomy, genioglossus advancement and hyoid suspension. Combining nasal/palate and tongue base surgery, the success rate can reach 70 to 80 percent.
Maxillomandibular Advancement Surgery
Maxillomandibular advancement surgery is a more aggressive procedure, usually saved for times when more conservative surgery fails. It involves the forward movement of the lower jaw and mid-face and gives the tongue more room, opens the airway more and places additional tension on the tongue base.
The individualised use of soft tissue and skeletal procedures for upper airway reconstruction ensures that the most conservative treatment is offered and the possibility of unnecessary surgery reduced.
Transoral Robotic Surgery (TORS) for Obstructive Sleep Apnoea
The da Vinci robotic surgery system allows the surgeon superior access and view of the tongue base and hypopharyngeal area not previously possible. It allows the surgeon to address airway obstruction secondary to lingual tonsillar hypertrophy, tongue base hypertrophy and floppy epiglottis.
Hypoglossal Nerve Stimulation
Hypoglossal nerve stimulation is a novel form of therapy that has been shown to be effective in treating OSA by increasing upper airway muscle tone during sleep. This is achieved by an implantable device implanted beneath the skin in the chest that is switched on by the patient just before sleep. This device then applies mild stimulation of the hypoglossal nerve that supplies the tongue. The rate of this stimulation is synced to the patient’s breathing pattern to achieve the optimal amount of tongue protrusion needed to relieve tongue base obstruction as the patient inhales during sleep.
The information provided on this page does not replace information from your healthcare professional. Please consult your healthcare professional for more information.
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