On Choosing Between Scylla and Charybdis
Surgery For Snoring Due To Obstructive Sleep Apnea

The average individual who is presented with an option between two, or even more, different approaches to treatment for a serious illness usually defers to the referred specialist or permits the family physician to weigh the consequences and make the final decision. Unfortunately there are potential flaws involved in this reasoning. For example, the specialist may favor a specific approach because he or she has more experience in that technique or may actually be the researcher who developed the technique. Had the patient been referred instead to a competitor the experience or research may have been directed toward an entirely different procedure. As for the family physician, who would have little or no experience with either procedure, the decision, if any is forthcoming at all, would in all likelihood favor the referred specialist for several obvious reasons.

This all too common decision-making problem for patients is magnified even more when the choice between techniques involves a surgical procedure. This thought was brought sharply to my attention when I spotted two articles published sequentially in the April 2002 Archives of Otolaryngology, Head and Neck Surgery dealing with the surgical management of snoring due to obstructive sleep apnea. Anyone by now who has been reading the newspapers is probably aware of the well-touted link between snoring with repetitive short episodes of non-breathing and its association with brain damage and even death. Briefly, first described in 1965, the condition may be of central origin or local obstructive origin. The central form occurs when the brain fails to send the proper signals to those muscles responsible for breathing. The obstructive form is far more common and is due to a blockage in the nose or mouth. The result is a pause in breathing even though efforts to do so continue. This can occur as many as 20 to 60 times every hour, and is usually accompanied by snoring between the pauses. These individuals are often excessively sleepy during the day and may have early morning headaches. Early recognition and treatment of a sleep apnea are important because it may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke.

The two articles that I noticed involved different surgical approaches to a blockage caused by that little hanging piece of tissue called the uvula which can be seen at the back of the mouth. The first article came from Israel. Finkelstein and colleagues wrote a fairly discouraging article about the popular laser treatment in their treatise called "Laser-Assisted Uvulopalatoplasty for the Management of Obstructive Sleep Apnea: Myths and Facts." This method was introduced in 1990 but Lauretano's group writing in Laser Surgical Medicine back in 1997 claimed that the procedure was ineffective for this condition, was often followed by subjective delayed failures, and could even lead to aggravation of sleep patterns in snorers who didn't have apnea. Perhaps they just didn't use the technique properly, but they were backed up in 2000 by Ryan and Love who claimed that many patients actually got worse following treatment, that the results were unpredictable, and that only a few patients improved satisfactorily. Their article appeared in Thorax. At this point it may be wise to seriously consider the potential pitfalls of this technique since Finkelstein's group concluded that favorable results could be achieved, but as time goes by these results deteriorate. They blame this on narrowing and fibrosis caused by the laser beam.

The second article is more encouraging, but the procedure used seems somewhat complicated and scary. It was reported by Vilaseca et al from Spain in their article entitled "Usefulness of Uvulopalatopharyngoplasty With Genioglossus and Hyoid Advancement in the Treatment of Obstructive Sleep Apnea." Even the rather involved title seems scary enough. Basically, the technique includes removal of a portion of the soft palate and the uvula, which by itself can be effective in 33% to 77% of patients. However, when patients have obstruction at more than one level the other phases can be added according to the method of Riley et al introduced in 2000. Vilaseca's surgeons performed the procedure on 20 patients and concluded that results using the full procedure were likely to be beneficial when applied to patients with mild to moderate obstructive sleep apnea syndrome. To say the least, neither one of these appraisals is exactly encouraging.

So where does all this leave the sufferer contemplating surgery for a condition that could potentially cause brain damage or even death? That's right, between Scylla and Charybdis. Frankly, if surgery is truly indicated - and don't forget that surgery can also be a big risk - the final decision seems to me to be a bit of a crapshoot.