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Go and Snore No More

TIMES HEALTH WRITER

Even when he was a young man in the Army, David Parker could snore with the bears.

“We had open barracks at the time. I remember in basic training, I was sleeping upstairs. Well, not only did the guys upstairs complain about my snoring, so did the guys downstairs,” recalls Parker, now 46.

And during his 16 years of marriage, patience has been truly a virtue for his wife, Carolyn.

“She would either go to another bedroom or sleep on the couch,” says Parker, of Los Angeles. “It makes me feel so bad that she had to do this. At one point, she taped me. I couldn’t believe it when I heard myself.”

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But help may be within earshot for Parker. Within a few weeks, he will be among the maiden group in Los Angeles to undergo a new treatment for severe snoring.

“I want to be the first one,” an anxious Parker says.

The technique, called laser-assisted uvulopalatopharyngoplasty, involves surgical removal of some tissues in the throat to open the airway that causes blockage and snoring. And although there is already a waiting list for the surgery, the procedure isn’t without controversy.

“It’s still a new and unverified procedure. I think it will be validated, but right now it has more publicity than factuality,” says Dr. Martin L. Hopp, an ear, nose and throat surgeon affiliated with the Sleep Disorders Center at Century City Hospital.

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The procedure is being widely touted as an outpatient treatment for loud snoring. Some experts suggest that it might also help people with obstructive sleep apnea, a serious condition in which the person stops breathing for dangerous periods of time during sleep.

But some doctors are concerned that patients who snore loudly will request surgery without first getting a thorough evaluation at a sleep disorders clinic to see if they have sleep apnea. They also want to see more studies verifying the procedure.

“There are studies in France, but we want to see it under our hands. Until we do that, I’m not comfortable recommending it, " says Dr. Jeffrey N. Hausfeld, medical director of the Sleep Disorders Center at Washington Hospital in Washington, D.C.

Studies by French researchers show a high success rate for people with simple snoring and apnea, although the studies have involved only a few apnea patients. Side effects--such as bleeding, infection, and swallowing and voice problems--have been minimal, the French researchers say.

And one ongoing study of the laser treatment in this country also appears promising in the treatment of both loud snoring and apnea.

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Snoring is a common problem that has long escaped easy solutions. There are more than 300 devices registered in the U.S. Patent and Trademark Office as cures for snoring, according to the American Academy of Otolaryngology. But, the academy notes, “99% of them work by keeping the snorer awake.”

Although the field of sleep disorders therapy has blossomed during the past 10 years, there are still no sure-fire treatments for severe snoring or apnea, Hopp says. And patients with the worst problems--an estimated 20 million--are often desperate for help.

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“It’s not unusual to have someone come in who says, ‘I’m getting divorced because I can’t sleep with my spouse. I snore too much,’ ” Hopp says.

There have been few remedies for people who snore in quaking tones, experts say. That’s why reports that laser-assisted uvulopalatopharyngoplasty can help have generated so much enthusiasm.

In the laser surgery, done in a series of four to six outpatient visits, the surgeon trims the soft palate and the uvula--the pouch of tissue that dangles from the roof of the mouth--with a precise laser beam.

The laser is useful because it reduces bleeding and swelling and is less painful than traditional surgery. Patients can have a moderate-to-severe sore throat for up to six days and usually miss a day or two of work. About four weeks of healing time is needed between treatments.

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According to Sharplan Lasers of Allendale, N.J., which manufacturers the laser and teaches the procedure to surgeons, studies in France show a dramatic reduction of snoring in 85% of 345 patients studied.

But Hopp and other sleep experts accuse the manufacturer and the media of hyping the surgery before American studies are completed. The laser is already approved for use in the United States. An ongoing American study of 300 people indicates that the procedure might benefit both sleep apnea patients and people with benign snoring. At St. Luke’s-Roosevelt Hospital in New York, 85%-90% of those with benign snoring experienced a drastic reduction in snoring, and about 90% of those with sleep apnea saw an improvement in both snoring and breathing capacity, says Dr. Yosef Krespi, director of the hospital’s ear, nose and throat department.

“In patients without apnea, the loudness of the snoring is diminished to a degree that they can start moving back into their bedrooms,” Krespi says. “In patients with apnea, we see tremendous improvement in oxygen intake during sleep and a reduction in how many apnea episodes they are having per hour.”

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Apnea is usually diagnosed after an evaluation at a sleep disorders clinic (the patient is tested during sleep) and is often treated with surgery, including a non-laser type of uvulopalatopharyngoplasty, which is similar to the laser technique but usually involves removing more tissue, Hopp says.

In traditional uvulopalatopharyngoplasty, the uvula and soft palate are cut back and the tonsils removed to open airways. The surgery is done under a general anesthetic, and the patient is hospitalized for a few days.

The surgery is about 50% effective, Hopp says.

“In some cases after the surgery, the patient still has blockage at the base of the tongue,” he says. “So we were disenchanted with this operation.”

But the surgery is still performed on patients who are thought to be particularly good candidates for it, he says.

The advantage of the laser surgery, Hopp says, is that doctors can check the patient after each stage of the surgery to see if it’s working, and that patients may experience less pain and fewer side effects, he says.

But until the U.S. studies are published, many surgeons urge caution.

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“We’re going to tell our first patients that they are guinea pigs,” says Hopp, who will begin offering the procedure at Century City Hospital in early January. St. John’s Hospital in Santa Monica is also offering the surgery, and Cedars-Sinai is expected to offer it early next year.

Others say they will not recommend the surgery until more is known about it.

The potential for scarring that might cause permanent swallowing and speech problems is especially worrisome, says Washington Hospital’s Hausfeld, although the French studies showed no cases of voice or swallowing problems.

Another concern is that the technique will become so popular that patients will demand--and receive--it without first getting a thorough evaluation. Some patients who have sleep apnea may have the procedure and see a reduction in their snoring. But they may still have dangerous apnea, says Dr. Nelson Powell of the Stanford University Sleep Disorders Center.

“If you go in and remove this alarm mechanism--the snoring goes away--and the patient has not been evaluated properly for apnea, then you’ve really done a disservice,” Powell says. But, he says, some patients will hear about the laser surgery, seek treatment for their snoring and will find out they really have sleep apnea.

“In some respects, the (publicity) this has gotten will uncover a lot of people with bona fide sleep apnea. A good head and neck surgeon will do formal study and make sure they are doing the right treatment,” Powell says.

The laser procedure will cost from $2,000 to $5,000 and probably will not be covered by insurance unless patients can show they are being treated for severe apnea that endangers their overall health.

As for living without one’s uvula, Hopp says, it appears to be relatively unimportant. The uvula is thought to be useful in some languages that feature a clicking sound. And it may help sweep the throat to clean it. But “We haven’t seen a lot of problems in patients who have had it removed,” Hopp says.

David Parker thinks he can live without his uvula. But he can’t go on with snoring.

“I’m very hopeful this will work,” he says. “I requested it as soon as Dr. Hopp gets the equipment. . . .

“And Carolyn thinks anything that could help would be absolutely wonderful. I don’t know how anyone could be so patient as to put up with this.”

BACKGROUND

Snoring is caused by an obstruction in the flow of air through the passages at the back of the mouth and nose. As a person relaxes during sleep, the tissues fold into each other, narrowing the air passages and creating a cacophony of clacking, snorting, gurgling, whistling and buzzing. The blockage can also be caused by nasal congestion, enlarged tonsils and adenoids, cysts and tumors. About 45% of adults snore occasionally and about 25% are habitual snorers. Snoring moves beyond the realm of being a mere nuisance when it wakes other people and when it is a symptom of obstructive sleep apnea.

Snoring Surgery In a new procedure to reduce snoring - called laser-assisted uvulopalatopharyngoplasty - surgeons use a precise laser to cut back some of the tissues in the throat that block the airway and cause snoring. The Soft Palate: The soft palate is trimmed. The Uvula: The small pouch of tissue that dangles from the roof of the mouth is reshaped.


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