Ira L. Shapira, DDS, FICCMO
Surgery on the soft palate has been a popular treatment for snoring and sleep apnea beginning with the UP3 or uvulopaltophayngealplasty. Initially it was thought that this surgery would eliminate sleep apnea and snoring. However the procedure proved to have a very high morbidity, problems experienced secondary to the surgery, and was not successful in treating sleep apnea. Many studies have shown that while snoring was usually reduced, the reduction in apnea was minimal and usually still required treatment with a C-PAP. There was also the danger of creating silent apneics (patients whose snoring was eliminated but whose apnea was still severe). These patients often were misdiagnosed as being successfully treated when apnea remained.
So, what do we do for snoring? First, we must decide if there is benign snoring or if apnea, hypopnea or upper airway resistance syndrome is present. The second question is where the snoring is coming from. Is it nasal, soft palate or pharyngeal? There are numerous surgeries directed at the soft palate that are variations of the UP3. Laup or laser assisted uvuloplasty reduces soft tissue that vibrates. Laup is usually conducted through a series of surgeries that many patients find extremely traumatic but effective. I have heard patients describe it as feeling as though a blowtorch was used. The search for more comfortable procedures led to somnoplasty in which an electrode is placed into the soft palate and a series of lesions are made that heat the interior to 121 degrees centigrade. This process induces tissue necrosis and scaring that tightens the soft palate. This procedure also may need to be repeated several times. The latest procedure is snoreplasty where a sclerosing (hardening) solution is injected into the soft palate to stiffen it and reduce vibrations. Unlike other surgical procedures, there is much less discomfort and pain with snoreplasty. All of these procedures work for some patients for treating snoring but they are not effective usually for treating apnea.
At this point, it is worthwhile to consider how the soft palate functions. When breathing, the soft palate swings open like a door and directs the air into the trachea, when swallowing the soft palate closes off the nasal cavity to prevent food and liquids from entering the nose. If you have ever laughed when eating or drinking you have probably experienced failure of this action. One risk of surgically reducing the soft palate is creating a deficiency causing a nasal twang to the voice and permanent problems with food and liquids entering the nose. The soft palate is not able to swing open during an obstructive apnea episode because the tongue is in the way, much like placing your foot in front of a door. The mechanical obstruction blocks the motion. With the door, you can move your foot and open the door or take an axe to the door. In the same manner with apnea, you can cut away the soft palate or you can move the obstruction, most commonly the tongue. Cutting away the soft palate does not resolve the apnea because the tongue is still blocking the airway.
How do oral appliances work to treat snoring and apnea? The most common type of appliance is the mandibular advancer. The lower jaw is brought forward and with it the tongue comes forward because of how they are connected. As the tongue is brought forward, a pair of muscles (the palatoglossal muscles) that connect the soft palate to the tongue, create tension on the soft palate and reversibly tighten it. One adjustable appliance has been shown in some studies to be 98% effective in reducing or eliminating snoring without surgery. Because the appliance also brings the tongue forward they are frequently capable of treating, often eliminating the apnea as well as the snoring. One of my favorite appliances, has a built in volume control that allows the partner of the snorer to turn off the snoring while their partner sleeps by turning a small knob that advances the tongue and the jaw.
Regardless of how snoring is treated it is important to do a follow-up sleep test to assure that there is no apnea and that we have not created a silent apneic.