The most common and popular interventions for primary snoring are those that target the soft palate, including injection snoreplasty, radiofrequency ablation, and surgical implants. The decision about which procedure to use often comes down to patient and provider preference. Dr. Volpi, for instance, offers patients a choice. “I describe both radiofrequency ablation and the Pillar procedure to the patient. The success rate is about the same for both procedures,” he said. “A lot of patients just don’t want something permanently implanted in them if they can avoid it, and the radiofrequency procedure avoids that.”
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April 2017It’s important to note that scar tissue created by radiofrequency “may start to soften over two or three years and may require repeat applications in the future,” Dr. Gillespie said.
Pillar implants, on the other hand, remain in the tissue and help maintain stiffness over time; however, “palatal implants are a really great example of a small intervention that means a small result,” Dr. Rotenberg said. “You’re not going get a huge bang for your buck, but you will get some noticeable improvements. If people are okay with that, then that’s perfectly fine.”
Patients who continue to have bothersome snoring after palatal implants may require additional surgery. “At that point in time, I’d do either a uvulopalatal flap or an expansion sphincterectomy, depending on the patient’s anatomy,” Dr. Rotenberg said.
Combination Treatments
One option used by some otolaryngologists, sometimes in conjunction with a dentist, is combination treatments. “I partner with a sleep dentist, and when we have a patient who wants maximum snoring reduction, we do a brief sedation and examine their airway to see where the snoring is coming from. Often, while they’re sedated, we’ll go ahead and do a nasal turbinate reduction to open the nasal passage, place Pillar implants to stiffen the soft palate, and fit them with an oral appliance,” Dr. Gillespie said. “We treat all three levels of the airway. It’s really the only way, I think, to get maximum snoring reduction.”
Such an approach can be convenient for both the patient and practitioner, in terms of scheduling, but can involve more discomfort than would be experienced after a single procedure, because more sites are involved. Physicians should carefully discuss the risks, benefits, and expected recovery process with patients.
“Some patients are not willing to consider combination approaches, but if they are, these multilevel approaches can be helpful,” said Eric Kezirian, MD, MPH, professor of clinical otolaryngology-head and neck surgery at the University of Southern California Keck School of Medicine in Los Angeles and president of the International Surgical Sleep Society.
Outcomes
It can be difficult to assess the effectiveness of snoring treatments, in both the short- and long-term, in large part because there is no good way to objectively assess snoring. Often, the standard for success is whether or not the bed partner remains annoyed. That said, “the studies we have basically suggest the results are improved noticeably with these treatments in the right patients,” Dr. Kezirian said. “However, results tend to get worse over time.” Whether that’s because scar tissues soften over time, because patients tend to gain weight over time, or because patients and partners perhaps overemphasize the benefits of snoring interventions immediately post-procedure is hard to say.