Dıagnostıc Methods For Snorıng And Obstructıve Sleep Apnea

Sleep Endoscopy

Have you ever wondered what happens in your throat when you snore or experience apnea (difficulty breathing) during sleep? Sleep endoscopy is a method designed to answer this question. This medical procedure allows doctors to observe how the airway behaves during sleep, helping to diagnose and treat issues like snoring and sleep apnea.

What is Sleep Endoscopy?

Sleep endoscopy, also known as drug-induced sleep endoscopy (DISE), is like a guided tour of your throat while you sleep. During the procedure, an anesthesiologist administers a mild sedative to mimic the relaxation that naturally occurs during sleep. In this semi-sleep state, a small camera is inserted through your nose to observe the lower part of the airway behind the nose.

The procedure identifies areas where blockages or collapses occur. Common sites of obstruction include:

• Soft Palate and Uvula
• Pharynx, Tonsils, Tongue Base

Since each individual’s airway behaves differently, this personalized information is highly valuable.

Why Do Doctors Use It?

Since my training in Pittsburgh in 2013, I have consistently used sleep endoscopy for patients with complaints of snoring and sleep apnea while planning treatment. This method helps pinpoint the exact location of the blockage in cases where the problem cannot be fully identified during an upright examination. Preoperative sleep endoscopy plays a crucial role as a guide to improving treatment success.

Sleep endoscopy is essential for diagnosing and treating breathing problems. Knowing where the obstruction occurs helps doctors choose the most appropriate treatment, whether it’s a CPAP device, an oral appliance, or surgery. If you’ve had surgery before, sleep endoscopy can show whether the treatment was effective and what may still be required.

Who Needs Sleep Endoscopy?

Your doctor may recommend this procedure if:

• Other tests cannot fully explain your symptoms.
• You do not respond to standard treatments like CPAP.
• Surgery is being considered for sleep apnea.
• Your airway anatomy is complex or unusual.

What is the Patient Experience Like?

Don’t worry—sleep endoscopy is a simple and safe procedure. The sedative makes you feel relaxed, and the camera does not cause pain. The procedure is completed in under an hour, and you can go home the same day.

What Are Its Drawbacks?

While sleep endoscopy is highly beneficial, it is not without limitations:

• Cost: It can be expensive and may not be widely available.
• Sedative Drug Effects: Though mild, sedatives may slightly alter airway behavior compared to natural sleep.
• Expertise Required: Interpreting results accurately requires skill.

What is Polysomnography?

Polysomnography is a comprehensive test that measures various body functions during sleep. It is typically performed in a sleep lab and monitors the following parameters:

• Brain Activity: Records electrical activity in the brain using EEG.
• Eye Movements: Determines REM (rapid eye movement) and sleep stages.
• Muscle Activity: Measures muscle tone and movements using EMG.
• Heart Rate and Breathing: Monitored with EKG and respiratory sensors.
• Oxygen Levels: Tracks blood oxygen saturation.

Polysomnography is used to diagnose sleep disorders such as sleep apnea, narcolepsy, and restless leg syndrome.

Polysomnography vs. Sleep Endoscopy: What Are the Differences?

Polysomnography and sleep endoscopy are two key methods used in diagnosing sleep disorders, each serving different purposes and being conducted differently. Here are the main differences between the two:

Main Differences

Purpose:

• Polysomnography: Analyzes sleep stages and general physiological parameters.
• Sleep Endoscopy: Examines the anatomical and dynamic features of the airway.

Application Field:

• Polysomnography: General diagnosis of sleep disorders.
• Sleep Endoscopy: Surgical planning for sleep apnea or evaluation of treatment success.

Application Method:

• Polysomnography: Conducted overnight in a lab setting using multiple devices.
• Sleep Endoscopy: A short procedure performed under sedation in an operating room.

Use of Results:

• Polysomnography: Determines the type of sleep disorder.
• Sleep Endoscopy: Guides treatment or decision-making for surgical intervention.

Sleep Apnea and Snoring Surgeries

Snoring can be a significant symptom of sleep apnea, but not every person who snores has sleep apnea. Especially if snoring occurs alongside breathing pauses or the person experiences a sensation of choking during sleep, this should be evaluated for sleep apnea. Simple snoring usually does not require treatment, but since sleep apnea can lead to serious health issues, it should always be assessed by a specialist. Early diagnosis and treatment are crucial in preventing complications caused by sleep apnea.

Surgical treatments for obstructive sleep apnea and snoring aim to regulate breathing by widening the airways from the nose to the throat. These surgeries generally focus on the nose, palate, tongue, and larynx areas. Depending on the location and severity of the obstruction, multiple areas may need intervention.

Nasal Region Surgeries

Nasal surgeries are generally less painful and have a quicker recovery time compared to interventions in other regions. These surgeries improve airflow by relieving nasal obstructions. However, they are not sufficient alone for treating snoring or obstructive sleep apnea. Open nasal passages can also enhance the effectiveness of CPAP (Continuous Positive Airway Pressure) devices.

Commonly Performed Surgical Types:

Septoplasty: When the septum, which divides the nostrils, causes obstruction due to its deviation or displacement, it is straightened and any bony protrusions are removed if necessary.

Concha Reduction: The size of the turbinates inside the nose is reduced to widen the airways.

Rhinoplasty: Although commonly known for aesthetic purposes, it is frequently performed to alleviate nasal obstructions.

Palate and Tonsil Region Surgeries
Palate surgeries shape the tissues at the back of the mouth to widen the airways. These surgeries are often combined with tonsil surgeries (tonsillectomy/tonsilotomy).

Commonly Performed Surgical Types:

Palatal Advancement: A portion of the hard palate is removed, and the soft palate is moved forward to open the airway.

Palatopharyngoplasty: The tissues around the soft palate and tonsils are removed and reshaped to expand the airway.

Tonsillectomy/Tonsillotomy: The removal or reduction of the tonsils to widen the airway.

Palatoplasty: Involves tightening or reducing the palate. These procedures may include removing a piece from the palate in a window shape, reducing the uvula (the small tongue, which should never be completely removed), and using radiofrequency to shrink tissues. These methods are usually preferred for treating snoring.

Tongue Region Surgeries

Surgical procedures for the tongue and tongue base (which can also be robotic) are performed to prevent the tongue from blocking the airway or to reduce its size. One of the main causes of obstructive sleep apnea is obstruction in the tongue and/or tongue base. Tongue surgery is usually combined with other methods or performed using minimally invasive techniques.

In some cases, the growth of the lingual tonsils (tongue base tonsils) can narrow the airway. However, obstructions caused by the volume of the tongue muscle are more complex and typically require midline tongue reduction surgery. In rare cases, the epiglottis or surrounding tissues at the top of the vocal cords may cause obstruction. Surgeries for these areas are performed only in specific patients.

Commonly Performed Surgical Types:

Lingual Tonsillectomy: Removal of enlarged lingual tonsil tissue.

Midline Glossectomy: A portion of the tongue muscle is removed to reduce its volume.

Tongue Suspension Surgery: A rarely used technique to stabilize the position of the tongue.

Epiglottic/Supraglottic Surgery: A rarely used method to eliminate obstructions in the epiglottic region (laryngeal valve).

Robot-assisted surgery for tongue base procedures is not required, but in certain situations, it is preferred to facilitate the surgeon’s work and enhance the precision of the operation. Robot-assisted surgery allows surgeons to perform more precise and controlled interventions, especially in difficult-to-reach areas like the tongue base.

Multilevel Surgery

Experts indicate that “multilevel surgery,” which focuses on more than one area—such as the nose, palate, tongue, and lateral pharyngeal walls—provides more effective results than focusing on a single region. Research shows that this approach is successful in patients with multiple obstruction sites. However, to achieve the best results from surgery, each patient’s cause of obstruction should be carefully analyzed, and an individualized treatment plan should be created.

Hypoglossal Nerve Stimulator: This innovative method stands out as a treatment for obstructive sleep apnea. This implantable device electrically stimulates the hypoglossal nerve, which controls the tongue muscles, causing the tongue to move forward and preventing the upper airway from closing.

The device works with a generator placed in the chest and an electrode connected to the nerve, sensing the breathing rhythm during sleep and offering a personalized treatment. Its minimally invasive nature allows for a rapid recovery process, and it provides an effective alternative for patients who cannot tolerate CPAP devices.

Clinical studies have shown that the device successfully reduces snoring, prevents breathing interruptions, and improves quality of life. The hypoglossal nerve stimulator offers an effective and safe solution in sleep apnea treatment, providing patients with a more comfortable life.

Complications

Although sleep apnea surgeries are effective, they carry certain risks. Postoperative pain, especially in the throat and tongue regions, can occur. Swelling may lead to difficulty in breathing and swallowing, which can even be life-threatening. Complications such as infection, voice changes, and in rare cases, nerve damage can arise. In some patients, sleep apnea may not be completely resolved even after surgery. A thorough pre-surgery evaluation and careful postoperative monitoring are crucial to minimize these risks.

Each type of surgery is specially planned according to the patient’s needs, with the goal of improving the airways and enhancing quality of life. A comprehensive evaluation with a specialist is required to determine the most appropriate treatment method.