Dr Anton van Lierop
Ear, Nose and Throat Surgeon
Snoring and sleep apnoea are common yet often under-recognized sleep disorders that can significantly impair quality of life and carry serious health risks. As an ENT (ear, nose, and throat) surgeon, understanding the pathophysiology, diagnosis, and, critically, the surgical intervention options are vital for providing comprehensive patient care.
Understanding Snoring and Sleep Apnoea
Snoring results from turbulent airflow caused by vibration of the soft tissues in the upper airway during sleep. While frequently dismissed as a benign symptom, habitual snoring can sometimes be a manifestation of obstructive sleep apnoea (OSA)—a condition characterized by repeated episodes of airway obstruction leading to apnoeic pauses, oxygen desaturation, and sleep fragmentation.
Obstructive sleep apnoea (OSA) is the most common form of sleep apnoea, accounting for approximately 84% of cases, and involves the collapse or narrowing of the pharyngeal airway. Central sleep apnoea, less common, results from a failure of the brain’s respiratory control centre to initiate breaths. The pathophysiology of OSA implicates anatomical factors such as enlarged tonsils, a hypertrophic palate, redundant or enlarged base of the tongue, a retrusive jaw, obesity-related fat deposits around the neck, nasal obstruction and neuromuscular factors that reduce airway stability.
Clinically, patients with sleep apnoea often report excessive daytime sleepiness, loud snoring, witnessed apnoeic episodes, and non-restorative sleep. In some cases, comorbidities such as hypertension, atrial fibrillation, stroke, and metabolic syndrome develop, creating a chronic disease burden.
Diagnosis and Assessment
Diagnosis relies on comprehensive clinical evaluation complemented by polysomnography to determine the severity of sleep apnoea (measured by the Apnoea-Hypopnoea Index, AHI) and identify the sites of obstruction. ENT surgeons play a crucial role in visualizing the upper airway, identifying anatomical abnormalities, and planning surgical interventions.
Treatment Options: An ENT Surgeon’s Approach
Management strategies aim to restore normal breathing and improve sleep quality. Continuous positive airway pressure (CPAP) remains the gold standard treatment for moderate to severe OSA, effectively splinting the airway open during sleep. Alternative options include mandibular advancement devices for mild to moderate cases, weight management, positional therapy, and, in some cases, surgical interventions.
While lifestyle modifications and non-invasive therapies such as CPAP are first-line treatments, surgical options become crucial for patients with anatomic causes of airway obstruction or CPAP intolerance. Surgical interventions aim to enlarge or remove obstructive tissues to restore a patent airway during sleep.
- Adeno-tonsillectomy or Uvulopalatopharyngoplasty (UPPP):
This traditional procedure involves removal of excess tissue from the soft palate, uvula, and tonsils to reduce vibratory tissue and open the oropharynx. It remains one of the most common surgical treatments but has variable success rates, especially in cases with multi-level occlusion. Adeno-tonsillectomy is the first treatment option in paediatric OSA.
- Nasal Surgery:
Addressing nasal obstructions—septoplasty, turbinoplasty, or nasal valve reconstruction—can improve airflow and reduce snoring, particularly when nasal resistance contributes to airway collapse.
- Other Surgical treatment Options: Laser Assisted Uvulopalatoplasty (LAUP) to reduce soft palate tissue, Pillar Implants to “stiffen” the palate, Radiofrequency Ablation to cause tissue shrinkage and stiffening, Transoral Robotic Surgery (TORS) for base of tongue reduction, Maxillomandibular Advancement (MMA) especially for cranio- facial abnormalities.
Surgical Decision-Making and Multilevel Approaches
Successful surgical management often entails a multilevel approach, addressing all sites of obstruction in the upper airway. The ENT surgeon conducts a thorough endoscopic evaluation, perhaps incorporating drug-induced sleep endoscopy (DISE) to observe dynamic airway collapse and identify key obstructive sites.
Patient selection and realistic expectations are critical. Surgical success rates vary, and post-operative polysomnography is essential to confirm efficacy. Combining surgical interventions with other therapies enhances outcomes in many cases.
Conclusion
As an ENT surgeon, offering a tailored surgical treatment plan can dramatically improve the health and quality of life of patients suffering from snoring and sleep apnoea. The advancements in minimally invasive techniques, combined with comprehensive assessment methods, have expanded the arsenal of effective surgical options. When appropriately selected and executed, these procedures not only alleviate upper airway obstruction but may also mitigate associated systemic health risks, exemplifying the vital role of ENT specialists in managing sleep-disordered breathing.
