Snoring, obstructive sleep apnea, and surgery.

Abstract

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, with or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction with contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity. Nonetheless, tracheostomy can be lifesaving and remains an option for patients with severe OSA with serious associated cardiovascular complications, who cannot tolerate CPAP, and for whom other interventions are ineffective or unacceptable. Effective surgical treatment of snoring has been accomplished with UPPP and LAUP. LAUP is less invasive, less morbid, more cost-effective, and better tolerated and is likely the most appropriate procedure for debilitating symptomatic snoring. Currently, LAUP is not recommended for the treatment of OSA, despite some efficacy in patients with mild OSA. Exclusion of OSA in patients undergoing LAUP for snoring is important.