ⅥSnoring

Treatment of Snoring

JMAJ 46(3): 133–138, 2003

Tadao NISHIMURA

Professor, ENT Department of Fujita Health University Second Hospital

Abstract:For proper treatment of snoring, it is important to perform inquiry, inspect the nasal cavity, and larynx, and hear the snoring sound by using a tape recorder. If sleep apnea syndrome (SAS) is suspected, overnight monitoring is performed. Dynamic MRI during sleep and upper airway endoscopy are very useful in the determination of sites responsible for snoring and SAS for the selec- tion of an appropriate therapeutic method. Treatment of snoring is broadly clas- sified into two major methods, conservative treatment and surgical treatment. Conservative treatment is indicated for the following cases: (1) high-degree obesity, (2) elderly patients or patients with heart diseases, (3) when improvement is not expected, and (4) when the patient is unwilling to undergo surgery. Conser- vative treatment includes (1) guidance of living, (2) medication, (3) nasal CPAP, and (4) use of dental appliances. Surgical treatment includes (1) intranasal opera- tion, (2) UPPP (uvulo-palato-pharyngoplasty), (3) LAUP (laser-assisted uvulo- palatoplasty), (4) LMG (laser midline ), (5) /adenoid- ectomy (especially for children) and (6) tracheotomy. It is important to select the proper method strictly based on the outcome of diagnosis. Key words:Snoring; Surgical treatment; Sleep apnea syndrome (SAS); Nasal CPAP (continuous positive airway pressure); Dynamic MRI

Introduction naturally quiet. The person himself is usually unaware of his snoring, but his snoring disturbs In times bygone, snoring was regarded as a the sleep of his/her bed partner or family. In symbol of a great man and large snoring sound addition, when a snorer goes traveling with was considered to reflect deep sleep. However, his/her friends or coworkers, he/she may be snoring, as matter of fact, is associated with two secretly worried whether his snoring would be problems. hated or ridiculed. The first problem is that loud snoring pro- The second problem is that loud every night duces noise during night when it should be snoring is suspected to be associated with sleep

This article is a revised English version of a paper originally published in the Journal of the Japan Medical Association (Vol. 127, No. 1, 2002, pages 74–78). The Japanese text is a transcript of a lecture originally aired on August 17, 2001, by the Nihon Shortwave Broadcasting Co., Ltd., in its regular program “Special Course in Medicine”.

JMAJ, March 2003—Vol. 46, No. 3 133 T. NISHIMURA

apnea syndrome (SAS). In other words, snor- Table 1 Conservative Treatment of Snoring ing is an inevitable symptom of SAS. In the ¥Treatment of obesity: presence of SAS, sleep is divided into fractions. Nutrition education, exercise therapy This results at times in daytime somnolence Mazindol (Sanorex) and also affects the circulatory disorders Chinese medicine (Bofu-tsu-sei-san, Dai-saiko-to, including hypertension and heart disease.1–3) Boui-ou-shi-to) ¥ Treatment of nasal allergy: Local remedy Diagnosis and Examinations for Tramazoline hydrochloride (Towk) Treatment of Snoring Oxymetazoline hydrochloride (Nasivin) Naphazoline nitrate (Privina) Investigation for the causes of snoring re- Tetrahydrozoline hydrochloride (Cor-Tyzine) quires inquiry, inspection (nasal cavity, oral cav- Nasal topical thermotherapy ¥ Other pharmacotherapy: ity and pharynx), hearing of snoring sound, and Acetazolamide (Diamox) monitoring of nocturnal sleep. Moreover, upper Progesterone preparations airway endoscopy and dynamic MRI under Tricyclic antidepressants drug-induced sleep have to be to performed. ¥ Other conservative treatment Life guidance 1. Inquiry Sleeping posture education Dental appliances Presence or absence of nasal obstruction, Nasal CPAP (nasal continuous positive airway pressure) midnight awakening, early morning headache, therapy daytime sleepiness, and fatigability are inquired.

2. Inspection It is important to observe the condition of treatment. the nasal cavity, oral cavity, and pharynx to examine for the presence of any abnormality. 4. Examinations Severe nasal obstruction is observed in some At the author’s clinic, patients are hospital- cases, and the cause is repletion of bilateral ized for 1 to 2 nights to perform overnight nasal cavities with polyps that induce mouth monitoring by polysomnography to examine breathing and obstruction at the root of the presence or absence of SAS and the sever- in inspiration during nocturnal sleep. In these ity of snoring. cases, snoring and/or SAS are expected to In addition, dynamic MRI and upper airway improve following polypectomy. If inspection endoscopy are performed under drug-induced reveals severe hypertrophy of tonsils, snoring sleep to determine the site responsible for and SAS are attributable to the hypertrophy of snoring and SAS.4) Dynamic MRI examination tonsil in both children and adults, and dramatic requires an expensive instrument and is avail- elimination of snoring and SAS is, therefore, able only at limited facilities, while the upper frequently experienced after tonsillectomy. airway endoscopy is relatively easy to perform and is very useful in the determination of the 3. Hearing of snoring sound therapeutic method. To determine the severity of snoring and the type of snoring, ‘vibratory type’ or ‘stenotic Actual Treatment of Snoring type,’ it is therapeutically useful to ask the patient to record his snoring sound during Treatment of snoring is broadly classified sleep at home using a tape recorder and to into two types, namely conservative and surgi- bring the tape to the clinic for reference during cal treatments.

134 JMAJ, March 2003—Vol. 46, No. 3 TREATMENT OF SNORING

1. Conservative treatment and exercise therapy against obesity may Conservative treatment is classified into be successful in reducing body weight and pharmacotherapy and treatment without medi- thereby improve snoring or SAS. Some cation. (Table 1) patients living an irregular life and consum- (1) Pharmacotherapy ing excessive alcohol may try to remove Pharmacotherapy is indicated in the follow- sleepiness by drinking canned coffee ing cases: (1) Patients with high-degree obesity, (canned-coffee syndrome). Life guidance (2) elderly patients or patients with heart dis- is extremely important in such patients. ease in whom operation is contraindicated, Furthermore, in order to make these (3) when it is not known whether any surgical patients realize their obesity, it is very treatment is available, (4) when the patient is effective to make them record their body unwilling to undergo operation. weight every day to graphically show the As a pharmacotherapy of snoring associated body weight change and to write a body with obesity, mazindol (Sanorex) is covered by weight diary. Furthermore, at the authors’ national health insurance for patients with a clinic, some patients are given instructions high-degree of obesity index of 70%, or BMI about meals by a nutritionist. (body mass index) of 35 or higher after 1992. In (ii) Regarding the guidance of sleeping pos- other words, pharmacotherapy is applicable to ture, improvement or even elimination of clinical treatment as an auxiliary therapy for snoring and/or SAS is achieved in many diet therapy and exercise therapy.5) In addition, patients who have snoring or SAS in a Chinese medicines including Bofu-tsu-sei-san, supine position by making them sleep in a Dai-saiko-to, and Boui-ou-shi-to are used to lateral position. However, some patients achieve weight reduction.6) have a habit of lying in a supine position For snoring associated with nasal allergy, and we advise them to attach a baseball on nasal drops of a vasoconstrictor agent before the back to keep a lateral position all the bedtime are effective for the treatment of nasal time. obstruction. In addition, a number of anti- (iii) Concerning the use of dental appliances, it allergic agents are available for internal use is necessary to make the appliance at the and most of the recently developed drugs effec- dentist. The appliance is a kind of a big tively improve nasal obstruction with little denture which when attached causes the sleepiness. Moreover, their concomitant use lower jaw to project forward and the pha- with local remedies improves nasal symptoms ryngeal cavity to enlarge, thereby produc- and is effective against snoring. ing easy respiration and reduced snoring Besides these, acetazolamide (Diamox), and/or SAS. It is effective for mild SAS progesterone preparations, and tricyclic anti- but is not indicated for complicated cases depressants are also used in pharmacotherapy with nasal diseases. against SAS or snoring though they are not so (iv) Nasal CPAP is generally not used for common. patients suffering only from snoring. How- (2) Conservative treatment other than ever, it may be indicated for cases of loud pharmacotherapy snoring associated with SAS. Nasal CPAP (i) Life guidance, (ii) instruction of sleeping involves the application of positive pres- posture, (iii) dental appliance, and (iv) nasal sure through the nose by a device during continuous positive airway pressure (CPAP) sleep and is often used in SAS patients in are also used.7) the United States. Also in Japan, it is the (i)Life guidance is considered as an impor- most popular medical therapy. The demer- tant therapy because guidance to living its of the method are that the patients need

JMAJ, March 2003—Vol. 46, No. 3 135 T. NISHIMURA

Table 2 Surgical Treatments of Snoring

(i) Intranasal operations (turbinectomy, intranasal septal correction, nasal polypectomy) (ii) UPPP (uvulo-palato-pharyngoplasty) (iii) LAUP (laser-assisted uvulo-palato-plasty) (iv) LMG (laser midline glossectomy) (v) Adenotonsillectomy (vi) Tracheotomy



ab c



d e

Operation field in suspended head position.

1. a: Before operation; b, c, d: Operation is 4. Then muscosal membrane of the palatopharyngeal conducted in this order.; e: Completed. arch is excised as shown in c. (area with slant lines) 2. Operation is performed, in principle, in the 5. d: Anterior pillar of fauces and palatopharyngeal suspended head position under general arch are sutured (part shown with ). During anesthesia. a: Bilateral palatine tonsils suturing, a relatively large suture is made so that were present before the operation. the ligated part does not split. Black silk thread is 3. Under general anesthesia, Davis’s mouth used as suture material so that it is not missed gag is used to open the mouth wide and during the removal of thread the tongue is excluded to provide wide 6. Uvula is excised in wedge-shape (d) and view for bilateral palatine tonsillectomy. sutured (e). Sutures are removed in 7Ð9 days b: Mesopharynx after tonsillectomy. postoperatively.

Fig. 1 UPPP (uvulo-palato-pharyngoplasty) technique (Quoted from Reference 8)

to wear a mask in bed every night and the 2. Surgical treatment device produces some sound. Therefore, it Surgical treatment is considered extremely is not indicated for all patients (applicable effective against snoring and SAS. Surgical to 60–80% of patients). Also, it is not treatment includes (i) intranasal operation, indicated for patients with severe nasal (ii) UPPP (uvulo-palato-pharyngoplasty), (iii) obstruction associated with nasal polyp, laser-assisted uvulo-palato-plasty (LAUP), (iv) septonasal flexure, hypertrophic rhinitis, laser midline glossectomy (LMG), (v) adeno- and nasal allergy. tonsillectomy, and (vi) tracheotomy. (Table 2)

136 JMAJ, March 2003—Vol. 46, No. 3 TREATMENT OF SNORING

ab c d

Operation is conducted in the order of a➞b➞c➞d. a: local anesthesia of soft ; b: longitudinal resection of the soft palate by using CO2 or KTP laser; c: excision of uvula

Fig. 2 LAUP (laser assisted uvulo-palatoplasty) technique (Quoted from Reference 9)

(i) Intranasal operation is a radical treatment dren. This technique is, also, very useful of snoring caused by nasal diseases includ- against severe hypertrophy of tonsils in ing bilateral nasal polyp, deflected nasal adults. septum, and swelling of inferior turbinate (vi) Tracheotomy is used in rare cases with a due to nasal allergy and of snoring associ- high-degree of SAS for which improvement ated with SAS. is not expected with any other treatment. (ii) UPPP operation (Fig. 1) is the most com- mon operation for snoring and SAS. This Conclusion operation is usually combined with tonsil- lectomy to enlarge the pharynx.4) According to an epidemiological survey in (iii) LAUP (Fig. 2) involves upward excision of Japan, SAS has a prevalence of about 2–4%

the bilateral soft palate by using CO2 laser and is always accompanied by snoring. In addi- followed by excising the uvula short.9) This tion, SAS has significant effects on hyperten- operation is widely used as an operation sion and respiratory/circulatory organs. Thus for snoring in Western countries. However, attention should be paid to loud nocturnal UPPP and LMG are required more than snoring and it is advisable to consult a physi- LAUP for the treatment of more severe cian for diagnosis and treatment at a special stenotic snoring. medical institution as early as possible. (iv) LMG (Fig. 3) is indicated for patients with a big tongue and for cases in which the tongue is forcefully drawn posteriorly REFERENCES downwards during inspiration to cause 1) Nishimura, T.: Sleep apnea syndrome. Oto- 10) obstruction at the pharynx. Rhino-Laryngology 1986; 29: 455–460. (in (v) Adenotonsillectomy has a dramatic effect Japanese) against snoring and SAS, especially in chil- 2) Nishimura, T.: Effect of surgery on sleep

JMAJ, March 2003—Vol. 46, No. 3 137 T. NISHIMURA

a b c

1. LMG is performed in accordance with the method of sides of the tongue (c). Woodson and Fujita. Under general anesthesia, Davis’s 3. If the pharyngeal part of tongue cannot be sufficiently mouth gag is attached to provide as wide view as possible viewed for operation, a laryngoscope may be inserted to of the posterior lower part of the tongue. The CO2 laser apply laser irradiation under it to the pharyngeal part of apparatus is set under a microscope and the posterio- the tongue as shown in the figure in the right below (c). medial part of the tongue tissue is deeply watered. In most 4. As a result of this operation, a concavity is formed in the cases, bleeding is insignificant due to the use of laser. posterio-medial part of the tongue and the root of the 2. Then the reticulum of tongue is excised superficially with tongue is drawn forward, thus enlarging the airway. laser (b). Next the excised parts (b) are sutured on both The suture is removed 7Ð9 days postoperatively.

Fig. 3 LMG (laser midline glossectomy) technique (Quoted from Reference 10)

apnea and snoring, Practica Otologica 1993; 7) Nishimura, T.: Pharmacotherapy for symp- 86: 1363–1370. (in Japanese) toms “Snoring” edited by Nakai, Y. Twenty- 3) Nishimura, T., Morishima, N., Hasegawa, K. et first Century’s Clinical Treatments in Otorhino- al.: Effect of surgery on obstructive sleep laryngology, 20 Pharmacotherapy, Nakayama apnea. Acta Otolaryngol Stockh 1996; Suppl Shoten, 2001; pp.209–214. (in Japanese) 523: 231–233. 8) Nishimura, T.: Surgical treatment for snoring 4) Nishimura, T., Hasegawa, K., Morishima, N. et and sleep apnea—UPPP and LMG. Otolaryn- al.: Determination of the site responsible for gology—Head and Neck Surgery 1996; 68(11): snoring by dynamic MRI and midline gloss- 84–87. (in Japanese) ectomy for sleep apnea syndrome. The Journal 9) Nishimura, T.: Laser-assisted surgery for snor- of the Japan Broncho-esophagological Society ing. Oto-Rhino-Laryngological Society of 1996; 47: 101–106. (in Japanese) Japan, Textbook of the Thirteenth Specialist 5) Ishizuka, Y.: Pharmacotherapy for sleep apnea Seminar, Kyoto, 1999; pp.117–119. (in Japa- syndrome. JOHNS 1999; 15: 1755–1760. (in nese) Japanese) 10) Woodson, T. and Fujita, S.: Laser midline 6) Yamakawa, K., Togawa, K., Miyazaki, S. et al.: glossectomy and lingualplasty for obstructive Treatments for obstructive sleep apnea and sleep apnea. ed. Fujita, S., et al. In Snoring and snoring, and their indication criteria. JOHNS Obstructive Sleep Apnea. 2nd ed., Raven 1991; 7: 925–932. (in Japanese) Press, New York, 1993.

138 JMAJ, March 2003—Vol. 46, No. 3