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Snoring is a sound produced by vibration of the soft tissues of the upper airway during sleep and is indicative of increased upper airway resistance. Studies estimate that 45% of men and 30% of women snore on a regular basis. It can affect not only the snorer’s sleep but also the sleep of a spouse or other family members nearby. In fact, snoring causes many couples to sleep in separate rooms and often places strain on marriages and relationships. Recent evidence suggests that snoring may even cause thickening of the carotid arteries over time and potentially increase risk of stroke.

Snoring also may be a sign of a more serious health condition known as obstructive sleep apnea (OSA), characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times through the night. Most patients who snore should receive a comprehensive sleep evaluation, by a trained physician, that often includes sleep testing either done in the home or sleep laboratory.

1) Palatal stiffening procedures

  • Palatial Implants: – Palatal implant therapy, also known as the Pillar procedure, involves the placement of three polyester implants into the soft palate under local anesthesia in the office.  The implants, in conjunction with the body’s scarring response, result in stiffening of the palate, and subsequently, less vibration and flutter that causes snoring.  Potential benefits of this method include ease of application, minimal discomfort, fast recovery and potentially more long-term benefit.  Complications are rare but include implant extrusion requiring replacement. The primary drawback for many patients considering this option is the relatively high cost of the implants.
  • Injection Snoreplasty: – In this method, also done under local anesthesia in the office, a chemical is injected into the soft palate.  The subsequent inflammation and scar tissue stiffen the palate, therefore decreasing vibration and snoring.  The most commonly used agent is Sodium tetradecyl sulfate which has been used in the treatment of varicose veins.  Injection snoreplasty has the advantage of lower cost than other methods but is associated with more pain and recovery time.  Some patients may also require additional injection treatments to achieve optimal results.
  • Radiofrequency: – Radiofrequency treatment, also an office-based procedure performed under local anesthesia, uses heat to stiffen portions of the soft palate.  Multiple treatment sessions may be required to achieve the desired results.  Discomfort and recovery are generally less than injection snoreplasty but more than palatal implants.  Cost of radiofrequency also usually falls in between the other two options.

2) Tonsillectomy/Adenoidectomy

Enlarged tonsils and adenoids are a common cause of snoring and sleep disruption in children. The tonsils are clusters of lymphoid tissue in the back of the throat while the adenoids are a similar mound of tissue in the back of the nose. Although less commonly a problem in adults, some adults can receive excellent resolution of snoring through removal of enlarged tonsils and/or adenoids.
 
As opposed to the above office-based procedures, tonsillectomy/adenoidectomy is an outpatient surgery performed in the operating room under general anesthesia. Most patients require a recovery time at home of approximately one week but may continue to experience a sore throat for two weeks. The most common complication is bleeding, often occurring over a week after the surgery. Serious bleeding is rare.

3) Nasal Surgery

Increased nasal congestion has been shown to cause or contribute to snoring. Nasal obstruction may result from many causes, including allergies, polyps, septal deviation and turbinate hypertrophy. Medical treatment options, such as a nasal steroid spray or allergy management may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment.

One surgical option, known as radiofrequency turbinate reduction (RFTR), can often be performed in the office setting under local anesthesia. RFTR uses radiofrequency heat to shrink swollen tissues in each side of the nose. Other nasal surgeries, including septoplasty and polyp removal, are usually performed in the operating room under general anesthesia. In select patients, treatment of nasal congestion can result in improvement or resolution of snoring.

What else should I know?

There are also other available treatments such as oral appliances, nasal devices, positional therapy and a variety of over-the-counter products. Careful patient and procedure selection is critical to successful management of snoring. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

Tonsils and adenoids are the body’s first line of defense as part of the immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. Your ear, nose and throat (ENT) specialist can suggest the best treatment options.

What are tonsils and adenoids?

Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin and armpits. Tonsils are the two round lumps in the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments.

What affects tonsils and adenoids?

The two most common problems affecting the tonsils and adenoids are recurrent infections of the nose and throat, and significant enlargement that causes nasal obstruction and/or breathing, swallowing and sleep problems.

Abscesses around the tonsils, chronic tonsillitis and infections of small pockets within the tonsils that produce foul-smelling white deposits can also affect the tonsils and adenoids, making them sore and swollen. Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.

When should I see a doctor?

You should see your doctor when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose and throat and examine the head and neck. He or she may use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

  • Medical history
  • Physical examination
  • Throat cultures/Strep tests - helpful in determining infections in the throat
  • X-rays – helpful in determining the size and shape of the adenoids
  • Blood tests – helpful in diagnosing infections such as mononucleosis
  • Sleep study, or polysomnogram – helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.

Tonsillitis and its symptoms

Tonsillitis is an infection of the tonsils. One sign is swelling of the tonsils. Other symptoms are:

  • Redder than normal tonsils
  • A white or yellow coating on the tonsils
  • A slight voice change due to swelling
  • Sore throat, sometimes accompanied by ear pain
  • Uncomfortable or painful swallowing
  • Swollen lymph nodes (glands) in the neck
  • Fever
  • Bad breath

Enlarged tonsils and/or adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:

  • Breathing through the mouth instead of the nose most of the time
  • Nose sounds “blocked” when the person speaks
  • Chronic runny nose
  • Noisy breathing during the day
  • Recurrent ear infections
  • Snoring at night
  • Restlessness during sleep, pauses in breathing for a few seconds at night (may indicate sleep apnea).

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.
 
Chronic infections of the adenoids can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.

How to prepare for surgery

Children

  • Talk to your child about his/her feelings and provide strong reassurance and support
  • Encourage the idea that the procedure will make him/her healthier.
  • Be with your child as much as possible before and after the surgery.
  • Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness.
  • Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
  • It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
  • Your otolaryngologist can answer questions about the surgical procedure.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Your doctor may ask to you to stop taking other medications that may interfere with clotting.

  • Tell your surgeon if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, the surgeon should be informed.
  • A blood test may be required prior to surgery.
  • •A visit to the primary care doctor may be needed to make sure the patient is in good health at surgery.
  • You will be given specific instructions on when to stop eating food and drinking liquids before surgery. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced.

When the patient arrives at the hospital or surgery center, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of pre-operative and post-operative care and answer your questions.

After surgery

There are several post-operative problems that may arise. These include swallowing problems, vomiting, fever, throat pain and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately. It is also important to drink liquids after surgery to avoid dehydration.

Any questions or concerns you have should be discussed openly with your surgeon.

Improving Form and Function of the Nose

Each year thousands of people undergo surgery of the nose. Nasal surgery may be performed for cosmetic purposes, or a combination procedure to improve both form and function. It also may alleviate or cure nasal breathing problems, correct deformities from birth or injury, or support an aging, drooping nose.

Patients who are considering nasal surgery for any reason should seek a doctor who is a specialist in nasal airway function, as well as plastic surgery. This will ensure that efficient breathing is as high a priority as appearance.

Can Cosmetic Nasal Surgery Create a “Perfect” Nose?

Aesthetic nasal surgery (rhinoplasty) refines the shape of the nose, bringing it into balance with the other features of the face. Because the nose is the most prominent facial feature, even a slight alteration can greatly improve appearance (some patients elect chin augmentation in conjunction with rhinoplasty to better balance their features). Rhinoplasty alone cannot give you a perfect profile, make you look like someone else or improve your personal life. Before surgery, it is very important that the patient have a clear, realistic understanding of what change is possible as well as the limitations and risks of the procedure.

Skin type, ethnic background and age will be among the factors considered preoperatively by the surgeon. Except in cases of severe breathing impairment, young patients usually are not candidates until their noses are fully grown, at 15 or 16 years of age. The surgeon will also discuss risk factors, which are generally minor, as well as where the surgery will be performed – in a hospital, freestanding outpatient surgical center or a certified office operating room.

To reshape the nose, the skin is lifted, allowing the surgeon to remove or rearrange the bone and cartilage. The skin is then re-draped and sutured over the new frame. A nasal splint on the outside of the nose helps retain the new shape during healing. If soft, absorbent material is placed inside the nose to stabilize the septum, it will normally be removed the morning after surgery. External nasal dressings and splints are usually removed five to seven days after surgery.

When Should Surgery Be Considered to Correct a Chronically Stuffy Nose?

Millions of Americans perennially suffer the discomfort of nasal stuffiness. This may be indicative of chronic breathing problems that don’t respond well to ordinary treatment. The blockage may be related to structural abnormalities inside the nose or to swelling caused by allergies or viruses.

There are numerous causes of nasal obstruction. A deviated septum (the partition between the nostrils) can be crooked or bent as the result of abnormal growth or injury. This can partially or completely close one or both nasal passages. The deviated septum can be corrected with a surgical procedure called septoplasty. Cosmetic changes to the nose are often performed at the same time, in a combination procedure called septorhinoplasty.

Overgrowth of the turbinates is yet another cause of stuffiness. (The turbinates are the tissues that line the inside of the nasal passages.) Sometimes the turbinates need treatment to make them smaller and expand the nasal passages. Treatments include injection, freezing and partial removal. Allergies, too, can cause internal nasal swelling, and allergy evaluation and therapy may be necessary.

Can Surgery Correct a Stuffy, Aging Nose?

Aging is a common cause of nasal obstruction. This occurs when cartilage in the nose and its tip are weakened by age and droop because of gravity, causing the sides of the nose to collapse inward, obstructing air flow. Mouth breathing or noisy and restricted breathing are common.

Try lifting the tip of your nose to see if you breathe better. If so, the external adhesive nasal strips that athletes have popularized may help. Or talk to a facial plastic surgeon/otolaryngologist about septoplasty, which will involve trimming, reshaping or repositioning portions of septal cartilage and bone. (This is an ideal time to make other cosmetic improvements as well.) Internal splints or soft packing may be placed in the nostrils to hold the septum in its new position. Usually, patients experience some swelling for a week or two. However, after the packing is removed, most people enjoy a dramatic improvement in breathing.

What Treatment Is Needed for a Broken Nose?

Bruises around the eyes and/or a slightly crooked nose following injury usually indicate a fractured nose. If the bones are pushed over or out to one side, immediate medical attention is ideal. But once soft tissue swelling distorts the nose, waiting 48-72 hours for a doctor's appointment may actually help the doctor in evaluating your injury as the swelling recedes. (Apply ice while waiting to see the doctor.) What’s most important is whether the nasal bones have been displaced, rather than just fractured or broken.

For markedly displaced bones, surgeons often attempt to return the nasal bones to a straighter position under local or general anesthesia. This is usually done within seven to ten days after injury, so that the bones don't heal in a displaced position. Because so many fractures are irregular and won't “pop” back into place, the procedure is successful only half the time. Displacement due to injury often results in compromised breathing so corrective nasal surgery, typically septorhinoplasty, may then be elected. This procedure is typically done on an outpatient basis, and patients usually plan to avoid appearing in public for about a week due to swelling and bruising.

Will Insurance Cover Nasal Surgery?

Insurance usually does not cover cosmetic surgery. However, surgery to correct or improve breathing function, major deformity or injury is frequently covered in whole or in part. Patients should obtain cost information from their surgeons and discuss with their insurance carrier prior to surgery.

What is an Oral Appliance?

Oral appliances are one of the treatment options for snoring and obstructive sleep apnea (OSA). These devices are similar to mouth guards or orthodontic retainers that are worn in the mouth during sleep. They are designed to prevent soft tissue in the airway from collapsing and causing obstruction. These appliances can be used alone or in combination with Continuous Positive Airway Pressure (CPAP) or surgery.

How do Oral Appliances Work?

Oral appliances work by repositioning the lower jaw and/or pulling the tongue forward.  Mandibular-repositioning devices keep the lower jaw in a protruded position during sleep. This keeps the airway open by preventing the tongue and soft tissue in the throat from collapsing. Tongue-retaining devices hold the tongue with a suction bulb, preventing the back of the tongue from obstructing the airway during sleep.

What are the Indications for Oral Appliances?

Oral appliances are most effective in treating snoring and mild to moderate sleep apnea. These appliances are recommended for patients who are non-compliant with CPAP and fail positional and weight loss therapy. They can also be used for patients with moderate to severe OSA who cannot tolerate CPAP use. Oral appliances are also recommended for patients who fail, refuse or are otherwise not candidates for surgical treatment.

What are the Advantages of Oral Appliances?

Oral appliances provide a non-invasive alternative for treatment of snoring and sleep apnea. In comparison to CPAP, they have a higher compliance rate, are more compact and less cumbersome.

What are the Disadvantages of Oral Appliances?

With the use of oral appliances, patients may develop excessive salivation, dry mouth, tooth and jaw discomfort, permanent changes in occlusion, and temporomandibular joint disorder.  Some patients discontinue the use of oral appliances due to these side effects.

What are the other Treatment Options for Obstructive Sleep Apnea?

Treatment options for OSA include lifestyle modifications, weight loss, sleep positioning, CPAP and various surgical procedures to reduce airway obstruction.

The ear, nose and throat specialist will prescribe many medications (antibiotics, decongestants, nasal steroid sprays, antihistamines) and procedures (flushing) for treating acute sinusitis. There are occasions when physician and patient find that the infections are recurrent and/or non-responsive to the medication. When this occurs, surgery to enlarge the openings that drain the sinuses is an option.

A recommendation for sinus surgery in the early 20th century would easily alarm the patient. In that era, the surgeon would have to perform an invasive procedure, reaching the sinuses by entering through the cheek area, often resulting in scarring and possible disfigurement. Today, these concerns have been eradicated with the latest advances in medicine. A trained surgeon can now treat sinusitis with minimal discomfort, a brief convalescence and few complications.

A clinical history of the patient will be created before any surgery is performed. A careful diagnostic workup is necessary to identify the underlying cause of acute or chronic sinusitis, which is often found in the anterior ethmoid area, where the maxillary and frontal sinuses connect with the nose. This may necessitate a sinus computed tomography (CT) scan (without contrast), nasal physiology (rhinomanometry and nasal cytology), smell testing, and selected blood tests to determine an operative strategy. Note: Sinus X-rays have limited utility in the diagnosis of acute sinusitis and are of no value in the evaluation of chronic sinusitis.

Sinus Surgical Options Include:

Functional endoscopic sinus surgery (FESS):
Developed in the 1950s, the nasal endoscope has revolutionized sinusitis surgery. In the past, the surgical strategy was to remove all sinus mucosa from the major sinuses. The use of an endoscope is linked to the theory that the best way to obtain normal healthy sinuses is to open the natural pathways to the sinuses. Once an improved drainage system is achieved, the diseased sinus mucosa has an opportunity to return to normal.

FESS involves the insertion of the endoscope, a very thin fiber-optic tube, into the nose for a direct visual examination of the openings into the sinuses. With state-of-the-art micro-telescopes and instruments, abnormal and obstructive tissues are then removed. In the majority of cases, the surgical procedure is performed entirely through the nostrils, leaving no external scars. There is little swelling and only mild discomfort.

The advantage of the procedure is that the surgery is less extensive, there is often less removal of normal tissues, and can frequently be performed on an outpatient basis. After the operation, the patient will sometimes have nasal packing. Ten days after the procedure, nasal irrigation may be recommended to prevent crusting.

Image guided surgery:
The sinuses are physically close to the brain, the eye and major arteries, always areas of concern when a fiber optic tube is inserted into the sinus region. The growing use of a new technology, image guided endoscopic surgery, is alleviating that concern. This type of surgery may be recommended for severe forms of chronic sinusitis, in cases when previous sinus surgery has altered anatomical landmarks, or where a patient’s sinus anatomy is very unusual, making typical surgery difficult.

Image guidance is a near-three-dimensional mapping system that combines computed tomography (CT) scans and real-time information about the exact position of surgical instruments using infrared signals. In this way, surgeons can navigate their surgical instruments through complex sinus passages and provide surgical relief more precisely. Image guidance uses some of the same stealth principles used by the United States armed forces to guide bombs to their target.

Caldwell Luc operation:
Another option is the Caldwell-Luc operation, which relieves chronic sinusitis by improving the drainage of the maxillary sinus, one of the cavities beneath the eye. The maxillary sinus is entered through the upper jaw above one of the second molar teeth. A “window” is created to connect the maxillary sinus with the nose, thus improving drainage. The operation is named after American physician George Caldwell and French laryngologist Henry Luc and is most often performed when a malignancy is present in the sinus cavity.