Surgery a valid treatment option for snoring
1 JUNE 2011
Snoring is a symptom and a sign of airway obstruction and in serious cases can significantly increase the risk of cardiovascular events. It is a heterogeneous condition so to effectively treat it requires a multidisciplinary approach, according to Wollongong ENT head and neck surgeon Dr Stuart MacKay.
Writing in the latest edition of Australian Prescriber, Dr MacKay says while continuous positive airway pressure (CPAP) remains the gold standard treatment for snoring and sleep apnoea, mandibular advancement splints or surgery are also viable treatment options.
“Estimates suggest that 30% or more of patients cannot or will not use CPAP in the long term. These patients can be considered for either counselling to promote CPAP use, contemporary surgical airway reconstruction or mandibular advancement splint use.”
Mandibular advancement splints are intraoral appliances designed to improve or cure snoring by increasing the retrolingual airway and, due to the tongue’s attachment to the soft palate via palatoglossus and overlying mucosa, may even improve the retropalatal airway at the same time.
“A mandibular advancement splint is a viable alternative in moderate to severe obstructive sleep apnoea when CPAP has failed, but success rates are considered less. In some instances, surgery and device use may be combined to improve efficacy, but mostly single modality treatment is preferred,” Dr MacKay says.
In cases where CPAP and device use have failed, surgery is a valid treatment option.
“Surgical treatment options are multiple and often staged, despite patient perceptions that a single procedure will be curative. Tonsil and tongue size have implications for surgery. In patients with large tonsils (grade 3 or 4) and favourable tongue size (small – grades 1 or 2), modified uvulopalatopharyngoplasty with bilateral tonsillectomy should be considered, and in my opinion should be considered the gold standard treatment.”
In many cases, lifestyle modifications can help, particularly where obesity or alcohol play a role.
“Obstructive sleep apnoea is strongly associated with obesity and the importance of weight loss is well recognised. Personal trainers and dietitians can help patients with weight problems and concomitant cardiovascular risk factors, as well as surgical patients in whom subsequent weight gain or regain would be detrimental.”
“Alcohol consumption exacerbates snoring, and reducing or giving up alcohol should be advised. Other factors increasing cardiovascular risk such as smoking, diabetic control, hypertension and hypercholesterolaemia need to be addressed.”
“Sleeping on the side or in a more upright position rather than supine or prone is sometimes recommended but lacks strong evidence. As a general rule, over-the-counter remedies have limited proven efficacy in the treatment of snoring,” Dr MacKay writes.
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Australian Prescriber is an independent peer-reviewed journal providing critical commentary on therapeutic topics for health professionals, particularly doctors in general practice. It is published by NPS, an independent, not-for-profit organisation for quality use of medicines funded by the Australian Government Department of Health and Ageing. Australian Prescriber is published every two months, in hard copy that is distributed to health professionals free of charge, and online in full text at www.australianprescriber.com