Dr. Hazenfield -- Ear, Nose, and Throat Doctor in Hawaii

Sleep Disorders:  Snoring and Sleep Apnea

Hugh N. Hazenfield, M.D., F.A.C.S.

•   Snoring

Snoring is an age-old problem with many social consequences, including marital discord, separate bedrooms, even separation and divorce, and angry neighbors.  Snoring usually occurs due to vibration of the tissue in the throat, usually while the patient is breathing through the mouth. 

A vibrating uvula

Although in itself snoring is not necessarily dangerous, it may be a symptom of sleep apnea or other sleep disorders -- conditions which can be very dangerous.  Until recently, the treatment for snoring has included such techniques as behavioral modification, weight loss, dental devices, nasal strips, drugs, and major (painful) surgery.  But now, the treatment for snoring and many cases of sleep apnea may be a simple office procedure.

•   Sleep Apnea

  • Sleep apnea is usually obstructive; that is, the breathing passage is blocked between the nose and the voice box.  If sleep apnea is severe enough, the oxygen in the bloodstream which is reaching the brain and other vital organs may fall to dangerous levels. 

  • The site(s) of obstruction must be diagnosed before treatment can begin.  This is done by a careful office examination.  There may be single or multiple sites of obstruction.  The following are the most common sites:

    Possible Sites of Obstruction

    

     

    • Nose: 

      Deviated septum

      Enlarged turbinates

      Polyps

       

    • Nasopharynx (the top of the throat behind the nose): 

      Enlarged adenoids

      Tornwaldt's cyst (rare)

       

    • Pharynx (the throat): 

      Enlarged tonsils

      Enlarged uvula or soft palate

      Enlarged base of the tongue

      Tongue base falling into pharyngeal airway

      Submucosal fat or redundant mucosa 

       

    • Larynx (voice box):

      Laryngopharyngeal reflux changes with severe posterior commissure swelling

     

  • Then, whether apnea is present or not and its severity is determined by a sleep study.  Once these are determined, treatment is targeted on relieving the obstruction.  

•   Treatment options for snoring and sleep apnea:

  • Weight reduction

  • Avoidance of alcoholic beverages, especially before retiring

  • Nasal CPAP, in which an appliance forces air at positive pressure into the patient's airway during sleep. 

    • For most patients, this works extremely well and invasive procedures can be avoided.  It is the "Gold Standard" of the treatment modalities for sleep apnea.  However, many patients cannot tolerate it and seek other treatments. 

    • If a patient cannot tolerate the various masks used with nasal CPAP, a trial using nasal pillows is suggested.  For many patients, this device seems to be much more comfortable than the masks.

    • Occasionally, for effective use of nasal CPAP and to improve the nasal airways, surgical straightening of the septum (middle structure) of the nose is necessary.

    • If nasal dryness and/or bleeding occur with the use of nasal CPAP, applying saline nasal gel in the nostrils prior to using the device may prevent these problems.

    • Dr. Hazenfield always recommends using nasal CPAP on a trial basis prior to progressing to invasive procedures.

  • Diathermy palatal reduction (office procedure effective for both snoring and mild-to-moderate sleep apnea)

  • Surgically straightening the septum (middle part) of the nose.  This usually works well for snoring, and it may be part of the recommended treatment for sleep apnea.  Also, it may help the patient better tolerate nasal CPAP.

  • Removing the tonsils and/or adenoids if enlarged

  • Uvulopalatopharyngoplasty (removing the uvula and part of the palate, or back part of the roof of the mouth) 

  • Other surgical procedures on the back portion (base) of tongue or through the neck

  • "Snoreplasty" or injection of sclerosing agents into the palate (for snoring only)

  • Implants of struts into soft palate; Pillar^™ palatal implants

  • Laser palatal reduction (for snoring only)

  • Various dental devices or major surgery on the jaw bones (usually for snoring only)

One method of treatment is not the answer for all patients with snoring and/or sleep apnea, and more than one treatment modality may be required.

•   Diathermy Palatal Reduction (Palatoplasty)

Doctor Hazenfield specializes in the treatment of snoring and sleep apnea.  He offers an office treatment called Diathermy Palatal Reduction (or "Diathermy Palatoplasty") for these conditions in his office in Hawaii.

•   Am I a candidate for the procedure?

Not all people with snoring are candidates for Diathermy Palatal Reduction.  Snoring can be associated with other conditions that may not be changed or improved by the procedure.  Some -- but not all -- patients with sleep apnea are candidates for this procedure.

Dr. Hazenfield will perform an examination of your upper airway to help differentiate simple snoring from a more significant breathing disorder, or to determine if there is another cause of your sleep disturbance.  Usually, a sleep study will be required.  Together, these will allow him to identify if you are an appropriate candidate for the procedure of diathermy palatal reduction.

•   What can I expect during the procedure?

This technique is an office procedure.  Low-power radio frequency energy is used to treat specific areas in the roof of the mouth.   Your mouth and throat are numbed with topical and local anesthetic.  Then radio frequency energy is delivered beneath the surface layer of the soft palate, causing scar tissue to form. 

Heating tissue with probe

Treated area in palate and uvula

forming scar tissue

Palate and uvula decreased in

bulk and tightened (8 weeks)

Notice that the palate and uvula

have less bulk, and the uvula is

shorter than in the preceding

picture.

The procedure usually takes less than fifteen minutes, usually creates little pain, and allows for a rapid recovery.  Most patients are able to resume normal activities within one hour afterwards.  Improvement or resolution of snoring usually occurs two to eight weeks after the procedure.

•   What can I expect after the procedure?

There may be some swelling and discomfort or pain for a few days following the procedure, similar to the feeling of an impending cold.  Snoring can be expected to be worse immediately after the procedure due to swelling of the tissues.  Improvement is usually seen after two weeks and continues to progress for up to several months.  At two months, you will know how much improvement has been achieved.  A subsequent procedure may be needed after two months following the initial treatment for further resolution of the problem.  Any post-operative discomfort is usually relieved with acetaminophen, ibuprofen or aspirin, but stronger medications are occasionally required.

•    What about the Pillar^™ implant system?

The Pillar^™ implant system is relatively new, having been approved by the FDA for snoring. 

I have performed only a limited number of these procedures.  I have not yet been able to evaluate the long-term results either in my own patients or in the medical literature.  Until those results are available, I am not performing nor recommending the procedure.

 

•   What about Snoreplasty?

Snoreplasty is also a relatively new procedure in which a sclerosing agent, usually Sotradecol^™, is injected into the palate, causing scar contracture.  To the best of my knowledge, this is still not approved by the FDA for this indication.

•   Uvulopalatopharyngoplasty?

Uvulopalatopharyngoplasty (UPPP) is a recognized treatment for sleep apnea, and when other treatment methods fail, Dr. Hazenfield may recommend that you undergo the procedure.  If the tonsils and adenoids are still present, they are removed at the same time.  Procedures on the base (back part) of the tongue may also be required.  Achieving a cure of sleep apnea with these procedures often degrades, with poor results five years after surgery in some patients.  The much simpler and less painful diathermy palatoplasty performed in the office may be all that is needed.

•   Is nasal surgery necessary?

Sometimes the nasal airways must also be improved with surgery.  The septum, or middle structure of the nose, is straightened, and small bones on the side of the nasal cavities called turbinates, may be reduced in size by various methods.  Nasal surgery may help the patient tolerate nasal CPAP by providing better airflow without resistance or obstruction.  It may be recommended to relieve snoring.  It may also be included as part of the surgery for sleep apnea.  If nasal surgery is required, Dr. Hazenfield will discuss that procedure with you.

For more information on snoring, sleep apnea, and its treatment, click here:

Snoring & Apnea