SNORING IN CHILDREN:
n childhood, snoring and especially apnea should be carefully monitored. Even a single apnea seen per hour requires urgent treatment in children. The most common causes of snoring and apnea in children are the presence and size of adenoids causing nasal obstruction, enlarged tonsils, growth of conchae due to causes such as allergic rhinitis and chronic sinusitis. While some of these diseases can be treated with medical treatment, removal of adenoids and tonsils with surgery is quite effective in treating snoring and apnea. Treatment of apnea and snoring due to facial skeletal anomalies is more difficult. These patients may require orthodontic treatment and jaw and facial surgeries.
SNORING IN ADULTS:
Snoring in adults occurs when soft tissues forming the upper respiratory tract vibrate while breathing. Blocked and vibrating areas can be examined by endoscopy during sleep; nasal conchae, soft palate, uvula, tonsils and tissues in the lower respiratory tract can vibrate. These tissues should be reduced by physiological methods so that they do not vibrate. I do not apply old, non-physiological methods such as removing the entire uvula or removing the soft palate together with the uvula. These techniques can cause irreversible problems such as food entering the nose, feeling of obstruction in the throat or inability to use CPAP in necessary cases.
SLEEP APNEA
The cessation of breathing for more than 10 seconds during sleep. It has a negative effect on the heart and vascular system in the long run by reducing oxygen saturation in the blood. The most common complaints are snoring, witnessed apnea, waking up tired, and daytime sleepiness. If there are more than 15 breathing stops per hour and low oxygen saturation is detected, it must be treated.
SLEEP TESTS:
Polysomnography (sleep test) is very important for differential diagnosis of sleep apnea. It allows us to determine the type, severity, and side effects of sleep apnea in the patient. Snoring and sleep apnea surgery should not be performed without a polysomnography test. Otherwise, unnecessary and incorrect surgeries can be performed.
SURGERY FOR SNORING AND OBSTRUCTIVE (BLOCKING) SLEEP APNEA IN ADULTS
USleep apnea is a complex and heterogeneous disease. Choosing the right treatment
method for the patient is very important due to its complex physiopathology. Only
obstructive sleep apnea patients can benefit from surgical treatment.
For successful results in snoring and obstructive sleep apnea, it is necessary to
"SELECT THE RIGHT PATIENT, PERFORM THE RIGHT SURGERIES IN THE RIGHT PLACES, WELL AND
SAFELY." If these stages are not carried out correctly and the patient is not well
selected, the result will be unsuccessful.
Regarding this complex disease, I determine the areas of obstruction during the
patient's sleep through physical examination and "sleep endoscopy" and apply the
necessary methods in the following.
TREATMENT METHODS FOR OBSTRUCTIVE SLEEP APNEA:
Nasal surgeries
Palatal surgeries
Parapharyngeal surgeries
Tongue surgeries
Hypoglossal nerve stimulator
Laryngeal surgeries
Skeletal surgeries
Bariatric surgery
Bypass of the upper airway (Tracheostomy).
Nasal surgeries
The aim of these surgeries is to create an open nasal airway and ensure nasal breathing. Therefore, the treatment of obstructive sleep apnea is not the primary goal of these surgeries. Nasal congestion and mouth breathing can increase negative pressure in the respiratory tract during sleep, exacerbating snoring and collapse of the upper airway, which can worsen sleep apnea.
PALATAL SURGERIES:
The palate refers to the soft palate. Soft palate problems can be seen in various anatomical structures. For example, a thick and saggy soft palate can cause snoring and apnea, while a thin and short soft palate can also be a cause of snoring. During sleep, the soft palate and uvula (the small, fleshy tissue that hangs from the soft palate) move according to changes in pressure in the upper airway. This movement varies from person to person and can cause closure of the airway in various ways, including anterior-posterior, lateral, and circular. The soft palate and uvula can cause snoring during sleep. The root of the tongue, along with the tonsils, can collapse and cause apnea and hypopnea. Soft palate surgeries can be performed using various methods such as cautery, radiofrequency, laser, or certain implants.
VELAR AND PHARYNGEAL SURGERIES:
Surgical procedures on the velar and pharyngeal areas, which include the soft palate
and the throat, are performed to prevent collapses in this area and to widen the
airway. The excessive size, looseness, and thickness of the soft palate, uvula,
tonsils, adenoids, and surrounding soft tissues in this area can cause snoring and
obstructions during sleep due to excessive movement and collapse. As a result,
snoring, apnea, and hypopnea occur. These problems can be resolved with the
following methods. The choice of surgical method used in patients is generally
determined by the surgeon's experience, the patient's anatomical structure, and the
surgical equipment and technology available. The surgical methods used for this area
are listed below. I choose the type of surgery based on the closure pattern seen in
sleep endoscopy. This is because sleep apnea is not a standard disease. There are
different levels and types of closure in each patient, and it is essential to
correctly identify these details for a successful surgical outcome.
•Tonsillectomy/Adenoidectomy
• Expansion Sphincter Pharyngoplasty
• Barbed Pharyngoplasty
• Cahali Lateral Pharyngoplasty.
• Z-Palatopharyngoplasty.
• Modified Uvulopalatopharyngoplasty.
• Hard Palate Surgery - Transpalatal Advancement Pharyngoplasty.
HYPOPHARYNGEAL SURGERIES:
The hypopharynx region is the lower part of the pharynx, located at the back of the tongue base and the beginning of the larynx. This area is a difficult area to reach, as it is both the beginning of the respiratory and digestive systems. Collapses and mobility of this region are associated with severe snoring and obstructive sleep apnea. Evaluation of this area is difficult both in normal examination and during sleep. With the sleep endoscopy method, we can evaluate these areas easily and more accurately during sleep. There are many surgical methods related to this region, as seen below. However, these methods have not become routine due to the difficulty of application, the possibility of postoperative disease, functional losses, and the difficulty of healing. Nowadays, we can access these regions more easily and safely with transoral robotic surgery. As a doctor, I mostly use robotic surgery in my personal practice, but I also use some of the following methods in appropriate patients.
HYPOPHARYNGEAL SURGERIES:
•Midline Laser Glossectomy
• Laser Lingualplasty
• Palatopharyngoglossoplasty
• Midline Glossectomy and Epiglottectomy
• Radiofrequency Tongue Volume Reduction
• Open Technique; Hyoepiglottoplasty with Tongue Base Reduction
• Tongue Base Coblation
• Radiofrequency-Assisted Tongue Reduction via Cervical Approach
• Endoscopic Coblation Lingual Tonsillectomy/Midline Glossectomy
• Open Technique; Tongue Base Reduction with Tirohyoidopexy
• Submucosal Minimal Invasive Tongue Excision
SUSPENSION SURGERIES:
These methods are performed as open surgeries, meaning that there is an incision on
the skin.
• Tongue/Tongue Base Suspension
• Modified Tongue Suspension
• Mandibulohyoid Suspension
• Tirohyoid Suspension (Hyoid Laryngeal Suspension/ Hyoid Myotomy)
MULTILEVEL ROBOTIC SLEEP APNEA SURGERY is discussed separately as a section for the
treatment of sleep apnea.
LARYNGEAL SURGERIES:
Tracheotomy is a life-saving method in very advanced cases, but it is not preferred
frequently due to the morbidity it causes. I perform other methods safely with
robotic surgery.
• Tracheotomy
• Epiglottoplasty
• Supraglottoplasty
• Transoral Robotic Supraglottoplasty
LARYNGEAL SURGERIES:
Tracheotomy is a life-saving method in very advanced cases, but it is not preferred
frequently due to the morbidity it causes. I perform other methods safely with
robotic surgery.
• Tracheotomy
• Epiglottoplasty
• Supraglottoplasty
• Transoral Robotic Supraglottoplasty
SKELETAL SURGERIES
In some patients with obstructive sleep apnea, lower and upper jaw anomalies are the
underlying main problems. Retraction of the lower and upper jaw, small size, and
narrowness of the palate are the most common skeletal disorders. This condition can
cause orthodontic problems and mouth breathing starting in childhood, while in
advanced ages, it can lead to severe sleep apnea syndrome. In these patients, we can
perform treatment with orthodontic and jaw surgery methods by making an early
diagnosis.
• Rapid Maxillary Expansion
• Maxillomandibular Advancement
• Mandibular Advancement
• Genioglossus Advancement
• Mandibulotomy
HYPGLOSSAL NERVE STIMULATION (HGNS)
This is a very new treatment method that we apply by selecting suitable patients. Electrodes placed in the oral cavity on the hypoglossal nerve, which causes the muscles that make up the base of the tongue to contract, prevent the tongue from collapsing into the airway during sleep by stimulating the nerve at intervals.
BARIATRIC SURGERY
Contrary to popular belief, less than ten percent of sleep apnea patients are morbidly obese. In overweight patients, obstructive sleep apnea may develop due to the fat accumulation in the soft tissues and base of the tongue in the upper airway. The most definite solution in these patients is weight loss. Bariatric surgery may be recommended for patients who cannot lose weight through diet and conservative methods.
