Clin.Ololurjngoi. 1992. 17, 525-521
The relief of snoring by nasal surgery P.D.M.ELLIS*, M.LL.HARRIES*, J.E.FFOWCS WILLIAMS? & J.M.SHNEEERSONf *ENT Department, Addenbrooke’s Hospital, Cambridge; ?Department of Engineering, Cambridge University; and $Papworth Hospital. UK Accepted for publication 3 July 1992 E L L I S P . D . M . , H A R R I E S M . L L . , F F O W C S W I L L I A M S J.E. & SHNEERSON I . M .
(1992) Clin. Otolaryngol. 17, 525-527
The relief of snoring by nasal surgery Patients with nasal obstruction may also complain of snoring. It is uncertain whether surgery which relieves the nasal obstruction will also relieve the snoring. We have reviewed 126 patients who complained of both nasal obstruction and snoring and who underwent nasal surgery. Snoring was completely relieved in 39 patients (31%), was less loud in a further 72 patients (57%), unchanged in I 1 and louder in 4. It occurred on fewer nights post-operatively in 61, on the same number in 24 and more frequently in 2. Patients who had nasal polypectomy as part of their nasal surgery obtained the greatest snoring relief. This study suggests that when snoring and nasal obstruction coexist nasal surgery should be considered as thc first line of surgical treatment. Keywords
nasal obslrurtion snoring nasal surgery
Patients are referred to our Sleep Disorders Unit complaining not only of snoring, but also of nasal obstruction. This is usually due to a deviated nasal septum, nasal polyps or swollen turbinatcs. Patients often ask whether or not an operation on the nose will relieve both the nasal obstruction and the snoring. Our clinical impression was that in some patients both symptoms were relieved and this prompted us to review our experience of the effects of nasal surgery on snoring.
Patients and methods 260 consecutive patients who had been admitted under a single consultant in Cambridge and had undergone an operation to relieve nasal obstruction between January 1989 and March 1990 were studied. Each subject was sent a questionnaire between 6 and 24 months after surgery. 172 (66%) of the patients returned the questionnaire satisfactorily completed. The questionnaire enquired whether both before and after surgery the patient’s nose felt clear or blocked, whether snoring was present and, if so, how loud and on how many nights each week it occurred. With the exception of the last question the patients’ replies were marked on a visual analogue scale from 0 to 10. A snoring index was derived by Correspondence: P.D.M.Ellis. ENT Department, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ. UK.
multiplying the loudness indicted on the visual analogue scale by the number of nights each week on which snoring occurred.
Results Of 172 patients who satisfactorily completed the questionnaire 46 did not snore before surgery, leaving 126 patients (73%) who complained of both nasal obstruction and snoring preoperatively. Five subjects reported that they did not snore before their operation, but did so afterwards. The hospital records of these 5 patients were reviewed to see if any common factor such as the type of nasal surgery or the cause of the nasal obstruction was involved, but none could be identified. Of the 126 patients who complained of nasal obstruction and snoring preoperatively, 39 (31 %) were completely relieved of their snoring after surgery. In the remaining 87 the snoring was less loud in 72, unchanged in I 1 and worse in 4,and occurred on fewer nights each week in 61, on the same number in 24 and more frequently in 2 subjects. For the whole group of 126 patients using the Pearson correlation coefficient method of analysis a statistically significant improvement in all the measures of snoring was demonstrated after surgery (P < 0.01). Those patients who had nasal polypectomy as part of their nasal surgery had a better reduction in snoring than the remainder. The questionnaire also asked how successful surgery had
525
526
P.D.M.Ellis el al.
Table 1. Effects of nasal surgery on snoring in patients complaining of nasal obsttuction and snoring (n = 126)
Nasal obstruction (mean VAS score Number
~-
SMR SMR, BINP SMR, CIT SMR, RIT
BINP BINP, CIT BINP, RIT CIT CIT, RIT RIT All patients
Pre-op
~-
No. of nightsiweek snored
Post-op
Pre-op
Post-op
Snoring index (mean VAS score x number of nights; week snored) Pre-op Post-op
-
~
Operation
Snoring loudness (mean VAS score
Post-op
Pre-op
____
.~
~
9 9 19 23 21 I1 4 19 2 3
8 9 8 8 9 8 8 8 8 7
2 3 2 3 3 3 3 3 2 2
6 6 6 6 6 7 7 6 8 6
3 3 3 3 2 3 3 3 5 3
5 5 5 5 5 6 5 5 5 5
3 2 2 3 2 2 2 3 5 3
30 30 30 30 30 42 35 30 40 30
126
8
2.1
6.7
3.3
5.3
2.1
35.5
9 6 6 9 4 6 6 9 25 9
8.9
SMR, Submucus resection; BINP, bilateral intranasal polypectoniy; CIT.cautery of infcrior turbinates; RIT, reduction of inferior turbinates; VAS, visual analogue scale
been in relieving nasal obstruction. 25 patients (20%) reported complete relief of the nasal obstruction, but the improvement in snoring was no different in this group from that in the other 101 subjects. A correlation between the improvement in nasal obstruction and in the snoring index was shown only in those who underwent nasal polypectomy as part of thier nasal surgery ( P< 0.001).
Discussion Regular loud snoring is a common and increasingly recognized problem. It has been found to occur in around 20% of adults and in as high a proportion as 50% of those over 60 years old.' It is frequently associated with rapid oscillation of the palate, particularly during inspiration. The extent to which the palate flaps will depend on the pressure difference across the membrane, the rigidity of the membrane, its mass, and the involvement of muscular action. The membrane cannot oscillate in the absence of a pressure difference but whether the difference is cause or effect is not yet clear. Nasal obstruction can alter these pressures and flows in the region of the palate by two mechanisms. Firstly, cessation of airflow through the nose reduces the stimulation of nasal receptors which normally activate the dilator muscles of the upper airway.l The result is that the airway becomes more compliant and can either close completely or become unstable and oscillate. Secondly, the high resistance in the nose requires a greater negative pressure to be generated during inspiration lower down in the airway to achieve an adequate flow of air. This also tends to narrow the airway and increase the air speed and probably facilitates oscillation of the palate. The same mechanism predisposes to obstructive sleep apnoea in which the airway remains occluded for
periods > 10 seconds. Loud snoring is a common presenting symptom of this condition.3 The standard operation for relief of snoring is uvulopalatopharyngoplasty; which involves resection of the tonsils if they are present and 1-2 cm of the edge of the soft palate including the uvula. The operation relieves snoring in 80-90% of subjects, but complications such as nasal regurgitation, pharyngeal stenosis and voice changes do occur' and a number of deaths have been reported.' Nasal obstruction is frequently associated with snoring' and the results of this study have shown the effectiveness of nasal surgery in improving snoring. 31% of the group no longer snored at all and a n improvement was seen with every type of procedure carried out on the nose. Five of the 172 patients, however, snored only after their operation. Nasal surgery can modify the airflow in a predictable fashion, but the oscillation of the palate depends also on other factors, including the pressure and the flow lower in the airway. It may be for this reasons that the results of nasal surgery on snoring cannot be precisely predicted. Nevertheless, surgery to relieve nasal obstruction improved snoring considerably in most of our patients and it should be the first line of surgical treatment when simple medical measures have already been tried.
References 1 LUGARESI R., CARIGNOTTA F., COCCAGNA G. & PIANA C. (1980) Some epidemiological data on snoring and cdrdio-respiratory
disturbances. Sleep 3, 221-224 J.E., DE GROOTW.J., SAUERLAND E.K. & ANCHA.M. 2 REMMERS (1978) Pathogenesis o f upper airway occlusion during sleep. Journal of Applied Physiology 44, 93 1-938
The relief of snoring b y nasal surgery
3 WOODHEAD C.J., DAVIES J.E. & ALLENM.B. (1991) Obstructive sleep apnoea in adults presenting with snoring. CIinical 0tolur)ingology 16, 40 1-405 4 FUJITAS., CONWAYW.. ZORICKF. & ROTH T. (1981) Surgical correction of anatomic abnormalities in obstructive sleep apnoea syndrome: uvulopalatopharyngoplasty. Ololuryngo/ogy Head and Neck Surgery, 89, 923-934 5 CROFT C.B. & GOLDING-WOODD.G. (1990) Uses and
527
complications of uvulopalatopharyngoplasty. Journal of Laryngology and Otology 104, 871 -875 6 FAIRBANKSD.N.F. (1 990) Uvulopalatopharyngoplasty complications and avoidance strategies. Ofo/aryngohgyHeadand Neck Surgery 102, 239-245 7 HOFFSTEIN v., CHABANR., COLE P. & RUBINSTEIN I. (1988) Snoring and upper airway properites. Chest 94, 87-89.
The relief of snoring by nasal surgery P.D.M.ELLIS*, M.LL.HARRIES*, J.E.FFOWCS WILLIAMS? & J.M.SHNEEERSONf *ENT Department, Addenbrooke’s Hospital, Cambridge; ?Department of Engineering, Cambridge University; and $Papworth Hospital. UK Accepted for publication 3 July 1992 E L L I S P . D . M . , H A R R I E S M . L L . , F F O W C S W I L L I A M S J.E. & SHNEERSON I . M .
(1992) Clin. Otolaryngol. 17, 525-527
The relief of snoring by nasal surgery Patients with nasal obstruction may also complain of snoring. It is uncertain whether surgery which relieves the nasal obstruction will also relieve the snoring. We have reviewed 126 patients who complained of both nasal obstruction and snoring and who underwent nasal surgery. Snoring was completely relieved in 39 patients (31%), was less loud in a further 72 patients (57%), unchanged in I 1 and louder in 4. It occurred on fewer nights post-operatively in 61, on the same number in 24 and more frequently in 2. Patients who had nasal polypectomy as part of their nasal surgery obtained the greatest snoring relief. This study suggests that when snoring and nasal obstruction coexist nasal surgery should be considered as thc first line of surgical treatment. Keywords
nasal obslrurtion snoring nasal surgery
Patients are referred to our Sleep Disorders Unit complaining not only of snoring, but also of nasal obstruction. This is usually due to a deviated nasal septum, nasal polyps or swollen turbinatcs. Patients often ask whether or not an operation on the nose will relieve both the nasal obstruction and the snoring. Our clinical impression was that in some patients both symptoms were relieved and this prompted us to review our experience of the effects of nasal surgery on snoring.
Patients and methods 260 consecutive patients who had been admitted under a single consultant in Cambridge and had undergone an operation to relieve nasal obstruction between January 1989 and March 1990 were studied. Each subject was sent a questionnaire between 6 and 24 months after surgery. 172 (66%) of the patients returned the questionnaire satisfactorily completed. The questionnaire enquired whether both before and after surgery the patient’s nose felt clear or blocked, whether snoring was present and, if so, how loud and on how many nights each week it occurred. With the exception of the last question the patients’ replies were marked on a visual analogue scale from 0 to 10. A snoring index was derived by Correspondence: P.D.M.Ellis. ENT Department, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ. UK.
multiplying the loudness indicted on the visual analogue scale by the number of nights each week on which snoring occurred.
Results Of 172 patients who satisfactorily completed the questionnaire 46 did not snore before surgery, leaving 126 patients (73%) who complained of both nasal obstruction and snoring preoperatively. Five subjects reported that they did not snore before their operation, but did so afterwards. The hospital records of these 5 patients were reviewed to see if any common factor such as the type of nasal surgery or the cause of the nasal obstruction was involved, but none could be identified. Of the 126 patients who complained of nasal obstruction and snoring preoperatively, 39 (31 %) were completely relieved of their snoring after surgery. In the remaining 87 the snoring was less loud in 72, unchanged in I 1 and worse in 4,and occurred on fewer nights each week in 61, on the same number in 24 and more frequently in 2 subjects. For the whole group of 126 patients using the Pearson correlation coefficient method of analysis a statistically significant improvement in all the measures of snoring was demonstrated after surgery (P < 0.01). Those patients who had nasal polypectomy as part of their nasal surgery had a better reduction in snoring than the remainder. The questionnaire also asked how successful surgery had
525
526
P.D.M.Ellis el al.
Table 1. Effects of nasal surgery on snoring in patients complaining of nasal obsttuction and snoring (n = 126)
Nasal obstruction (mean VAS score Number
~-
SMR SMR, BINP SMR, CIT SMR, RIT
BINP BINP, CIT BINP, RIT CIT CIT, RIT RIT All patients
Pre-op
~-
No. of nightsiweek snored
Post-op
Pre-op
Post-op
Snoring index (mean VAS score x number of nights; week snored) Pre-op Post-op
-
~
Operation
Snoring loudness (mean VAS score
Post-op
Pre-op
____
.~
~
9 9 19 23 21 I1 4 19 2 3
8 9 8 8 9 8 8 8 8 7
2 3 2 3 3 3 3 3 2 2
6 6 6 6 6 7 7 6 8 6
3 3 3 3 2 3 3 3 5 3
5 5 5 5 5 6 5 5 5 5
3 2 2 3 2 2 2 3 5 3
30 30 30 30 30 42 35 30 40 30
126
8
2.1
6.7
3.3
5.3
2.1
35.5
9 6 6 9 4 6 6 9 25 9
8.9
SMR, Submucus resection; BINP, bilateral intranasal polypectoniy; CIT.cautery of infcrior turbinates; RIT, reduction of inferior turbinates; VAS, visual analogue scale
been in relieving nasal obstruction. 25 patients (20%) reported complete relief of the nasal obstruction, but the improvement in snoring was no different in this group from that in the other 101 subjects. A correlation between the improvement in nasal obstruction and in the snoring index was shown only in those who underwent nasal polypectomy as part of thier nasal surgery ( P< 0.001).
Discussion Regular loud snoring is a common and increasingly recognized problem. It has been found to occur in around 20% of adults and in as high a proportion as 50% of those over 60 years old.' It is frequently associated with rapid oscillation of the palate, particularly during inspiration. The extent to which the palate flaps will depend on the pressure difference across the membrane, the rigidity of the membrane, its mass, and the involvement of muscular action. The membrane cannot oscillate in the absence of a pressure difference but whether the difference is cause or effect is not yet clear. Nasal obstruction can alter these pressures and flows in the region of the palate by two mechanisms. Firstly, cessation of airflow through the nose reduces the stimulation of nasal receptors which normally activate the dilator muscles of the upper airway.l The result is that the airway becomes more compliant and can either close completely or become unstable and oscillate. Secondly, the high resistance in the nose requires a greater negative pressure to be generated during inspiration lower down in the airway to achieve an adequate flow of air. This also tends to narrow the airway and increase the air speed and probably facilitates oscillation of the palate. The same mechanism predisposes to obstructive sleep apnoea in which the airway remains occluded for
periods > 10 seconds. Loud snoring is a common presenting symptom of this condition.3 The standard operation for relief of snoring is uvulopalatopharyngoplasty; which involves resection of the tonsils if they are present and 1-2 cm of the edge of the soft palate including the uvula. The operation relieves snoring in 80-90% of subjects, but complications such as nasal regurgitation, pharyngeal stenosis and voice changes do occur' and a number of deaths have been reported.' Nasal obstruction is frequently associated with snoring' and the results of this study have shown the effectiveness of nasal surgery in improving snoring. 31% of the group no longer snored at all and a n improvement was seen with every type of procedure carried out on the nose. Five of the 172 patients, however, snored only after their operation. Nasal surgery can modify the airflow in a predictable fashion, but the oscillation of the palate depends also on other factors, including the pressure and the flow lower in the airway. It may be for this reasons that the results of nasal surgery on snoring cannot be precisely predicted. Nevertheless, surgery to relieve nasal obstruction improved snoring considerably in most of our patients and it should be the first line of surgical treatment when simple medical measures have already been tried.
References 1 LUGARESI R., CARIGNOTTA F., COCCAGNA G. & PIANA C. (1980) Some epidemiological data on snoring and cdrdio-respiratory
disturbances. Sleep 3, 221-224 J.E., DE GROOTW.J., SAUERLAND E.K. & ANCHA.M. 2 REMMERS (1978) Pathogenesis o f upper airway occlusion during sleep. Journal of Applied Physiology 44, 93 1-938
The relief of snoring b y nasal surgery
3 WOODHEAD C.J., DAVIES J.E. & ALLENM.B. (1991) Obstructive sleep apnoea in adults presenting with snoring. CIinical 0tolur)ingology 16, 40 1-405 4 FUJITAS., CONWAYW.. ZORICKF. & ROTH T. (1981) Surgical correction of anatomic abnormalities in obstructive sleep apnoea syndrome: uvulopalatopharyngoplasty. Ololuryngo/ogy Head and Neck Surgery, 89, 923-934 5 CROFT C.B. & GOLDING-WOODD.G. (1990) Uses and
527
complications of uvulopalatopharyngoplasty. Journal of Laryngology and Otology 104, 871 -875 6 FAIRBANKSD.N.F. (1 990) Uvulopalatopharyngoplasty complications and avoidance strategies. Ofo/aryngohgyHeadand Neck Surgery 102, 239-245 7 HOFFSTEIN v., CHABANR., COLE P. & RUBINSTEIN I. (1988) Snoring and upper airway properites. Chest 94, 87-89.
