1
Introduction
Snoring is a highly prevalent condition consisting of irregular respiratory sounds during sleep that are sufficiently loud enough to disturb a bed partner. A recent large health survey found that 53% of adult Americans were regular snorers, including 59% of adult men and 46% of adult women. The high prevalence among adults is due in part to the rising incidence of obesity, with 71% of obese adults self-reporting snoring compared with 36% of normal-weight adults. The snoring sound is created by turbulent airflow through the upper airway caused by flow limitation from anatomic obstruction or tissue collapse from reduced neuromuscular tone. Snoring results in reduced sleep quality for the bed partner and in many cases the snorer themselves. Snoring is commonly the hallmark sign of obstructive sleep apnea (OSA), and therefore all chronic snorers need a thorough evaluation for OSA. Evidence exists, however, that snoring with or without OSA may be an independent risk factor for heart disease and stroke. Therefore snoring management should be considered for the benefit of the snoring patient in addition to the bed partner. Sling snoreplasty is a readily available, low-cost option for snoring management that has demonstrated promising results in initial studies. The technique, and its variations, all involve the use of suspension sutures to compress, stiffen, and reposition the soft palate.
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Patient Evaluation
Snoring management is initiated once a patient is determined to be at low risk for OSA. OSA management strategies covered elsewhere in this text must be considered before undergoing snoring therapy for any patient found to have moderate to severe OSA on overnight polysomnogram or found to have significant OSA risk factors on screening history and physical. Snoring management should begin with conservative measures to improve sleep and overall health. Patients should be encouraged to manage their weight, exercise three or more times per week, avoid alcohol and sedative medications, avoid upper airway irritants such as cigarette smoke, avoid eating within 3 hours of sleep, and try a positioning pillow or wedge if snoring is particularly severe in the supine position. If the patient has a history of allergy or chronic nasal obstruction, a 4- to 6-week trial of a daily prescription steroid nasal spray may be of benefit. Patients with nasal obstruction with associated lateral nasal wall collapse and positive Cottle sign may benefit from a trial of dilating nasal strips. Management of reflux laryngitis may reduce snoring in patients with upper airway irritation from chronic reflux.
Snoring is a complex disorder that can be managed, if not cured. A component of successful snoring therapy is the management of expectations of the snorer and their bed partner. Office-based procedures to reduce snoring generated from the soft palate will generally reduce snoring by approximately 50% if patients meet a set of common criteria for treatment. These criteria include nonobese (body mass index [BMI] ≤30 kg/m 2 ), benign snoring or mild apnea (Apnea/Hypopnea Index [AHI] ≤15), smaller tonsils (grade 0, 1), Friedman tongue position 1 or 2, and floppy soft palate collapse without significant tongue collapse on supine fiber-optic Mueller examination. Given the multilevel nature of sleep-disordered breathing, most patients will continue to have some snoring generated from untreated sites such as the nose and/or tongue. Therefore palatal snoring procedures often work best if combined with nasal surgery and/or oral appliances for maximal snoring reduction.
Office-based palatal procedures for snoring can be characterized as tissue reductive or tissue sparing . Tissue reductive techniques include uvulectomy and/or variations of laser-assisted uvuloplasty (LAUP). The popularity of LAUP has declined over the past decade largely due to the arrival of several tissue-sparing options that are equally effective but with fewer complications, less pain, and faster recovery. Tissue-sparing techniques are designed to induce stiffening in the body and edge of the soft palate to mute vibratory oscillations that create the snoring sound. Examples of tissue-sparing palatal snoring treatments include injection snoreplasty, Pillar palatal implants, and radiofrequency ablation. Sling snoreplasty is the latest palatal stiffening technique to join these more established methods of snoring reduction. The ideal palatal snoring treatment would be tissue sparing; affordable; performed under local anesthesia in a single stage; have minimal complications; and provide long-lasting, predictable results. Although no treatment meets all of these ideal characteristics, each technique has advantages and disadvantages that must be taken into consideration when deciding on a particular treatment for a given patient.
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Sling Snoreplasty With Permanent Thread: The Hur Technique
Hur is credited with the first description of applying suspension sutures for snoring reduction. The technique was developed to avoid the side effects and complications seen in tissue ablative techniques such as LAUP and uvulopalatopharyngoplasty, namely significant pain, prolonged recovery, foreign body sensation, nasopharyngeal regurgitation, and change in speech or swallowing. The technique uses sutures to shorten, tense, and lift the soft palate. In addition, it was proposed that suture-induced fibrosis would occur over time to add rigidity to the soft palate tissues.
The Hur technique is performed under local anesthesia in the office setting. It involves three 4.0 nylon sutures. One suture is placed in the midline of the soft palate, and one laterally on either side. Sutures are passed through the fibromuscular layer of the soft palate in a triangular or pentagonal pattern, with each exit hole serving as the next entry hole. Once the suture returns to the point of origin, the suture is tied and the knot buried under the mucosa ( Fig. 29.1 ).
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