• Snoring and sleep apnea are common conditions seen in 25 – 40% of the adult population. After a thorough consultation, a video naso-endoscopy of the upper airway is done to look for upper airway obstruction. The site and degree if obstruction is assessed by visual examination.
• An evaluation of the velopharyngeal airway and extent and nature of collapse is necessary.
• The position of the tongue base and site of upper airway collapse is important in the initial clinical assessment.

• A complete overnight polysomnograhpy (PSG) can be done at home, hotel or hospital.
• The sleep data is downloaded and analysed.
• The extent and degree of OSA including central or obstructive sleep apnea can be diagnosed. The degree of arousals and any periodic (PLB) leg movements are noted.

• One non-surgical treatment in addition to weight loss and exercise is that of nasal CPAP.
• Atmospheric air is compressed and forced through the upper airway, opening and splinting the collapsed airway and restoring non-obstructed sleep and alleviation of OSA. This is an effective, non-surgical procedure, provided the patient can tolerate the nasal mask. Patient compliance is important. The type of mask used is important as it is the interface between patient and machine.

• CPAP Therapy with Breeze Sleep Gear and Nasal Pillow One. Atmospheric air is compressed and forced through the upper airway, opening and splinting the collapsed airway and restoring non-obstructed sleep and alleviation of OSA. This is an effective, non-surgical procedure provided the patient can tolerate the nasal mask and pressure of air.

• Dental Splints can also be used to pull the mandible and base of tongue forward to open the oropharyngeal airway. These are effective for mild OSA and must be fitted by an appropriate specialist. The risk of these dental splints are that of injury to the Temporo-Mandibular Joints which may be compromised.

• A surgical option is generally offered after failure of nasal CPAP therapy unless there are obvious areas of obstruction with enlarged tonsils, polyps turbinate hypertrophy or rhinosinusitis.
• The aim of surgery is to widen and stiffen the oro-naso hypopharyngeal airway.
• It can be soft tissue surgery of the palate, tonsil and tongue base, or nasal cavity.
• It is essential that the nasal airway be clear also either medically or surgically.
• Today, we know that single level surgery alone is not as effective as multi-level surgery i.e. surgery of the nose, palate, and base of tongue at the same time.

• Soft Tissue Surgery of the Upper Airway
  • a. Oropharyngeal / Palatal Surgery
    • Besides traditional surgery with radiofrequency diathermy which causes collateral damage, edema and swelling, new technology like the Coblatior has become a major advance as a surgical tool.
    • Coblation works at about 100°C as compared to electrocautery at 400°C Hence there is precise tissue coagulation with little colateral damage.
    • Coblation can be applied to the soft palate as CAUP or tongue base application to reduce the size of the tongue base.
    • The fundamental principle today is multi-level surgery at the nose, velopharynx or oropharynx and base of tongue. In soft tissue surgery of the upper airway, these 3 levels are dealt with with the coblator to widen and stiffen the upper airway. Major obstructive lesions like enlarged tonsils or adenoids or nasal polyps are removed.
    • The Coblator is applied to the soft palate via channeling to scar the soft palate.
  • b. Tongue Base - Surgery of the tongue base is the most difficult. The tongue can be coagulated and reduced in size by COBLATION, or Partially excised or repositioned by slings to the anterior arch of the mandible.
• Bony Framework Surgery
  • In the extreme situation, if soft tissue surgery fails, then the Bi-Maxillary Mandibular advancement operation whereby the upper and lower jaws are mobilised and pushed forward to open up the upper airway. This is very extensive surgery and surgery of the last resort.

The most difficult part of surgical therapy is that of choice of site of obstruction and method of surgery. To date most patients are evaluated by eye-balling the upper air way on endoscopy to determine the site or sites of obstruction. There are research tools to determine the site of obstruction, but these have not been proven to be reliable and reproducible to be a gold standard in the evaluation of OSA.