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A New Treatment of Snoring: Sling Snoreplasty

with Permanent Thread


Jun Hur, MD, Phd, Department of Otolaryngology,
HURJUN ENT Clinic, Busan, Republic of Korea
Abstract

Results

OBJECTIVE:
To introduce sling snoreplasty with permanent thread.
STUDY DESIGN:
Ideal snoreplasty has merits such as minimal resection, minimal complications, and maximum
effect.
SUBJECTS AND METHODS:
Under local anesthesia, sling snoreplasty has been performed on 15 patients from January,
2006 to January, 2007. Sling snoreplasty is a three-dimensional suture technique applied to 3
portions of redundant soft palate to widen oro/nasopharyngeal spaces. Five patients were
operated on using sling snoreplasty. Ten patients were operated on using sling snoreplasty
with radiofrequency volume reduction. Two patients were operated sling snoreplasty twice.
Success was judged by snoring scales.
RESULTS:
After a mean follow-up of 12.5 months till June, 2007, 11 of 15 patients reported significant
improvement in snoring and sleep apnea. Three patients informed some improvement. One
was lost to follow-up. Patients had only little pain and normal diet on the next day after surgery.
There were minimal postoperative complications.
CONCLUSION:
Sling snoreplasty can be a new effective palatal snoring procedure with minimal side effects. It
can be combined with other snoring operations.

Additional partial uvulectomy was carried on 5 cases (male 3, female 2). Patients had some
pain for 2 to 6 hours postoperatively (PS2= 4-6) and they were able to have normal diet on the
next day after surgery without any significant pain (PS2= 0-1) except No. 15 patient (PS1= 7,
PS2= 5) who had SST with RFVR and both tonsillectomies by using radiofrequency (Table 1).
A 56 years old male recurred snoring and sleep apnea since he had a LAUP 5 years before in
other clinic and he complained pharyngeal discomfort due to the stricture of operative site. He
was operated on using SST with RFVR in May, 2006 and didn't come back after 1 day follow-up.
After 5 months postoperatively, author identified by phone that the patient was much satisfied
with the result and had the loss of foreign body sensation in pharynx.
In the view of differences between preoperative and postoperative snoring scales, 11 of 15
patients reported significant decrease in snoring and sleep apnea and three patients reported
some improvement. One was lost to follow-up (Table 1). There were minimal postoperative
complications of SST: no nasopharyngeal regurgitation, much less pain, almost no bleeding
or exposure, no disconnection of knots, no foreign body sense, no foreign body reaction, no
speech disturbance and no swallowing difficulty. Comparing preoperative photographs with
postoperative ones, widening of oro/nasopharyngeal space was inspected because of pulling
up redundant soft palate anterosuperiorly by using SST (Fig 2).

Introduction
Surgical methods for snoring and sleep apnea focus on widening spaces by resection or
volume reduction, and also focus on decreasing vibration by sclerosing of soft palate and
uvula. When the narrowing of oro/nasopharyngeal space is a major cause of snoring and sleep
apnea, we can consider oro/nasopharyngeal surgeries such as Uvulopalatopharyngoplasty
(UPPP),1 Laser-assisted uvulopalatoplasty (LAUP),2 Uvulopalatal flap (UPF), and resection of
soft palate by using radiofrequency etc. These surgical methods have disadvantages such as
long recovery time, postoperative pain, foreign body sense, pharyngeal discomfort,
nasopharyngeal regurgitation, or voice change etc. No resection methods such as
Radiofrequency volume reduction of soft palate (RFVR),3 Injection scleroplasty, and Palatal
impant4 could complement surgical demerits. However, no resection methods also have
demerits; it is difficult to predict the result and sometimes it needs to repeat several times for
the vague postoperative effect. After all, both surgical and non surgical methods have limits.
Ideal snoreplasty is considered to have merits such as minimal resection, minimal
complications, and maximum effect. Thus, author also has been trying to do a new method,
Sling snoreplasty with permanent thread (SST), to improve snoring and sleep apnea since
January, 2006. Idea was obtained from sling method used in ptosis.5

Figure 2 Oral cavity (00 endoscopic view): A. just before surgery, B. just after, C. 5 months later,
Nasopharynx (700 endoscopic view): D. just before surgery, E. 4 weeks later, F. 5 months later

Discussion
Methods
Preoperatively, informed consent for SST was obtained. After gargle anesthesia with 4%
lidocaine for 10 to 15 minutes, local anesthesia is done with 2% lidocaine with a 1:100,000
dilution of epinephrine at the soft palate. SST is a three-dimensional suture technique that has
been operated at 3 portions (the center and each side) of redundant soft palate to widen
oro/nasopharyngeal spaces. 4-0 or 3-0 Nylon (25mm, 3/8C, cutting) has been used as a suture
material. SST has been carried on the center of soft palate first. The starting point of sling
snoreplasty is at the pit point of the center between soft and hard palate. The first suture is
mainly performed counterclockwise with a triangular or pentagonal aspect from the starting
point (Fig 1). The insertion point of needle has to be exactly corresponded with the extraction
point of needle at each point (Fig 1). The depth of a bite has to be deep enough to get into
muscle layer. The ending point must precisely meet at the starting point. No incision is needed.
Tie is done about 5 to 7 times at the apex, the starting and ending point. Cutting is done just
near the knot which is buried into soft palate. Mostly, the second suture is carried out
clockwise at the right portion of soft palate and third suture is done counterclockwise at the
left with a triangular, rectangular or pentagonal form (Fig 1). When SST with RFVR is operated
simultaneously, RFVR is first and SST later. RFVR is performed into 2 points of the center and
2 points of each side. All patients receive prophylactic antibiotics and analgesics for 1 to 3
days.
SST was operated on 15 patients from January, 2006 to January, 2007. They were inspected
for the mean follow-up of 12.5 months till June, 2007. The operative results were evaluated by
using snoring scales (0= no snoring, 1-3= social snoring, 4-6= loud snoring, 7-9= very intense
snoring, 10= bed partner leaves room) and pain scales (from 0= no pain to 10= excruciating
pain). In the view of differences between preoperative and postoperative snoring scales, about
2 to 3 scales of improvement would be considered as some improvement and a descent of 4 or
more scales would be considered as significant improvement

No

Sex/Age

Op date

score1a

score2b

F/Uc

Ht/Wtd

BMI

PS1e

PS2f

M/47

20/01/06

17

165/62

22.8

M/55

15/02/06

16

173.5/73

24.3

M*+/41

16/02/06

10

16

167/81

29.0

M/30

24/02/06

10

16

174/71

23.5

M/51

28/02/06

10

16

168/84

29.8

M+/41

08/05/06

10

13

168/74

26.2

M/51

17/05/06

10

13

168/65

23.0

M/40

18/05/06

13

173/75

25.1

F+/54

24/05/06

13

150/50

22.2

10

M#/56

25/05/06

13

168/70

24.8

11

F+/62

02/06/06

12

158/49

19.6

12

M+/32

29/08/06

10

10

174/93

30.7

13

F*/57

11/10/06

10

153/57

24.3

14

M/46

17/01/07

173/63

21.0

15

M/20

23/01/07

10

177/74

23.6

Table 1 Patient Summary

Figure 1 Design for Sling Snoreplasty

a : preoperative snoring scales, b : postopeartive snoring scales in June, 2007


(0=no snoring at all, 1-3= social snorig, 4-6= loud snoring, 7-9= very intense snoring,
10= bed partner leaves room), c : follow up months till June, 2007, d : height(cm)/weight(kg),
e : pain score 2-6 hours later after surgery f : pain score the next day after surgery
(from 0= no pain to 10= excruciating pain), * : had 2nd SST, + : had uvulectomy,
# : had been operated LAUP in other clinic 5 years ago
(SST only: from No. 1 to No.2, SST and RFVR: from No.6 to No.15)

Results
According to the table, Sling snoreplasty was operated on 15 patients from January, 2006 to
January, 2007. 12 of 15 patients were men and 3 were women. The age ranged from 20 to 62
years (mean, 45.5 years). Men's ages ranged from 20 to 56 years (mean, 42.5 years). Women's
were from 54 to 62 years (mean, 57.7 years). Follow-up ranged from 6 to 17 months (mean, 12.5
months) till June, 2007. 5 cases were inspected for 16 to 17 months, 6 cases for 12 to 13
months, 1 case for 10 months, 1 case for 8 months and 2 cases for 6 months. The range of BMI
is from 19.6 to 30.7 (mean, 24.66). 5 cases had BMI more than 25.
Five patients (from No. 1 to No. 5) were operated on only SST and ten patients (from No. 6 to
No. 15) were operated on using SST with RFVR (Table 1). 2 of 15 patients had second
operation (male 1, female 1). A male had 2nd SST 5 months later after 1st SST and a female, 2
months later.

Structural problems are the narrowing of oro/nasopharyngeal space due to redundant soft
palate or the posterior displacement of hard palate, the narrowing of hypopharyngeal space
due to hypertrophy of lingual tonsil, and the narrowing of nasal space by turbinate
hypertrophy and septal deviation. These narrowing problems form negative pressure and
increase air velocity (Bernoulli Effect), which cause additional narrowing or collapsing of nasal,
oro/nasopharyngeal or hypopharyngeal space and result in snoring and sleep apnea.
Thin and loose soft palate and uvula are easy to stick to the posterior wall of
oro/nasopharyngeal space and this causes snoring and sleep apnea. It is just like thin plastic
wrap is easy to adhere to its surroundings (Plastic Wrap Effect). The posteroinferior
displacement of redundant soft palate narrows oro/nasopharyngeal spaces and makes it easy
to adhere to the posterior pharyngeal wall in supine position.
To reduce these causes of snoring and sleep apnea, author has been trying to transpose soft
palate anterosuperiorly to widen the spaces, enhance the tension, shorten the length of soft
palate, and conglomerate redundant soft palate by using SST. The results have been
satisfactory.
The tone of snoring sound may be predictable according to the vibration level of the
redundant soft palate and uvula. Long frequency and low tone sound results from much
redundant soft palate and uvula. Less loose soft palate and uvula result in short frequency
and high tone sound. For example, in case of tent or placard, we can hear the looser tent
causes the lower and louder sound while the tighter one causes the higher and lighter sound.
Very tightly fastened tent or placard makes much less or no sound (Tent or Placard Effect). It
is also compared with the sound of guitar string: the looser string makes the lower tone and
the longer frequency while the tighter string makes the higher tone and the shorter frequency
(String Effect). Like this, idea for SST was obtained from these effect. Low and loud snoring
sound changed into high and light sound after 1st SST in some cases. The sound improved a
lot after 2nd SST. Analyzing snoring sound would be a useful reference to decide operative
sites or to evaluate postoperative results.
In case of no resection, the patients had postoperative pain for 2 to 6 hours because the
mucosa was preserved and the knots were buried. On the next day after surgery, they could
have normal diet and carry on daily life as usual. If needed, partial uvular resection or the 2nd
SST could be done. SST has minimal postoperative complications such as postoperative pain,
nasopharyngeal regurgitation, foreign body sensation, pharyngeal dryness and discomfort,
speech disturbance, and swallowing difficult etc. The tightly tied knots are going to get buried
into soft palate. The knots are tied 5 to 7 times to prevent unfastening. SST, RFVR and partial
uvulectomy can be carried out simultaneously in the first operation and we can expect better
result than each method. Occasionally tonsillectomy or nasal surgery can be needed. We can
use the permanent threads such as nylon, polypropylene, polyester, polypropylene mesh, or
other biocompatible materials.

Conclusion
SST can be a new effective palatal snoring procedure with minimal side
effects. SST has the merits of both resection (widening of oro/nasopharyngeal
spaces) and no resection (safe, less pain, short recovery time and minimal
complications). It can be combined with other snoring operations such as
nasal, oropharyngeal, or hypopharyngeal snoring surgery. Long term follow
up and objective evaluation would be needed.

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