Galina Gennadyevna Zharova, ENT specialist, member of the European Rhinology Society, highest category physician. Dangerous OSA: According to the World Health Organization, more than 30% of the adult population snores, and approximately 60% of people over 60 snore. Snoring is a sound produced by the soft structures of the pharynx colliding with each other as air passes through narrowed airways. Approximately one-third of all snorers also suffer from sleep apnea syndrome—brief pauses in breathing during sleep. While snoring primarily causes discomfort to others, sleep apnea causes oxygen deprivation of the brain, disrupts cardiac and vascular function, leads to strokes, and can even cause sudden death in sleep. Obstructive sleep apnea syndrome (OSA) is a condition characterized by snoring, periodic collapse of the upper airway at the level of the pharynx and cessation of pulmonary ventilation, decreased blood oxygen levels, severe sleep fragmentation, and excessive daytime sleepiness. Often witnessed by waking loved ones, they anxiously watch as snoring suddenly stops, followed by a frightening pause in breathing, followed by a loud snore and the return of breathing. Sometimes, up to 500 pauses in breathing can occur per night, lasting up to 4 hours, leading to both acute and chronic oxygen deficiency and significantly increasing the risk of hypertension, cardiac arrhythmias, myocardial infarction, stroke, and sudden death in sleep. Patients with sleep-disordered breathing experience restless, shallow sleep, sweating and frequent urination at night, fatigue and headaches in the morning, severe daytime sleepiness, irritability, decreased memory and attention, and impotence. Treatment of snoring and OSA in severe cases consists of overcoming the resistance to airflow from the upper respiratory tract (URT) using the method of continuous positive inspiratory pressure (a mask with a CPAP compressor (a method of creating continuous positive airway pressure) or reducing this resistance by surgically expanding the lumen of the URT. We choose... The main thing in the successful treatment of snoring is the correct selection of patients according to a specific algorithm. It is known that brachycephalics and hypersthenics with a short neck are susceptible to constitutional snoring and OSA, and they will require surgical correction in the area of ??the soft palate and tonsils, lateral walls of the pharynx and the root of the tongue. In asthenics with a long neck, OSA is unlikely, and the cause of their snoring is nasal obstruction, defects of the lower jaw (micro- and retrognathia). A specialist of our Center, V.V. Filippov, has developed a computed tomography technique that allows us to obtain a reconstructed form A section of the upper airway from the nasal vestibule to the trachea with clearly visible areas of narrowing. We perform the M?ller test, which evaluates the degree of narrowing of the retropalatine space as a percentage using a flexible nasopharyngoscope. To assess daytime sleepiness, we use the Epworth Sleepiness Scale (ESS) questionnaire. However, the main criterion for selecting patients for surgical treatment of snoring is polysomnography - the "gold standard" for diagnosing snoring and OSA. The apnea-hypopnea index (AHI) is the number of episodes of cessation or reduction of at least 50% of airflow through the nose for 10 seconds or more during one hour of sleep. The AHI is the main diagnostic criterion for choosing a treatment method and prognosis for a given patient. An AHI of 10-20 refers to mild OSA, 20-40 to moderate severity, and more than 40 to severe OSA. We can expect complete success in surgical treatment of patients with pure ronchopathy and mild OSA. (AHI up to 20). No surgical method cures severe OSA, but in these cases snoring decreases by 20-50 dB, AHI decreases by 10-30, that is, the use of a CPAP mask may not be daily. Are traditions always good? All methods pursue the goal of expanding the upper respiratory tract by removing or reducing the volume of tissue in the path of the air stream (hypertrophied inferior turbinates, nasal polyps, adenoid vegetations, hyperplastic soft palate, posterior arches and uvula, palatine tonsils, lateral walls of the pharynx and root of the tongue). Classic "acute" methods (conchotomy, tonsillotomy, uvulopalatopharyngoplasty and uvulotomy, excision of a segment of the root of the tongue) are traumatic, associated with significant blood loss, require anesthesia, suturing of the palate and nasal packing. In the postoperative period severe pain, dysphagia and hypersalivation make the patient incapacitated for at least two weeks. Delayed complications are possible: nasal reflux, open nasal speech and nasopharyngeal stenosis. In this regard, in the last decade, preference has been given to gentle surgical methods using ultrasound, laser and radio wave devices. In this article, we will compare these three methods based on the literature, observation and our own experience of radio wave treatment of snoring with the Ellman-Surgitron device. Alternative treatment Ultrasonic disintegration (USD) of the inferior turbinates was used by us from 1989 to 1998 and was abandoned as a bleeding and ineffective method for eliminating nasal obstruction. Observing ultrasound somnoplasty and uvolalatopharyngoplasty in the ENT department of M.G. Leizerman (LORA-Don device), we noted the low energy power of the ultrasound, which was expressed in the absence hemostatic effect, severe bleeding, difficulty cutting tissue. There was no reduction effect with ultrasound somnoplasty. Thus, ultrasonic surgery for snoring appears to be ineffective and associated with blood loss. Laser treatment of snoring. In October 2003, a conference on modern laser surgery was held in Moscow, where Dr. Remacle from Belgium presented his extensive experience in successful laser treatment of snoring, consisting of vaporization, that is, evaporation with a laser beam of limited areas of the uvula, posterior arches, edge of the soft palate, anterior ends of the inferior turbinates and tonsils. Patient selection: snoring and mild apnea. Results: AHI reduction by 20, 70% of satisfied patients. But it is precisely his extensive experience with laser that allows Dr. Remacle to point out problems and determine contraindications to laser treatment - a small mouth; - increased reflexes (you cannot swallow during the session (!); - the distance of the patient's place of residence from hospital (outpatient treatment is contraindicated due to the risk of bleeding). The advantage here is the possibility of quick outpatient treatment under local anesthesia, which creates a sense of simplicity of the method. In reality, this apparent technical simplicity, coupled with the high cost of the equipment, results in a difficult postoperative period for the patient due to excessive laser energy (a temperature of 1200° C leads to tissue necrosis with severe pain, bad breath, salivation, and the inability to eat for up to one month). I have repeatedly, while providing care to such patients, observed abundant white-black necrotic plaques on the palate, trismus, and symptoms of intoxication from an overdose of strong painkillers. We have been performing radio wave treatment for snoring in the outpatient setting of CELT since April 1998 using the Ellman-Surgitron device. In 2001, already having three years of experience with this device, we studied radiosurgery snoring at the University Clinic of Professor W. Mann (Mainz, Germany), where a 10-watt Somnus monopolar radiosurgical device with a thermal sensor is used for this purpose, and came to the conclusion that Surgitron is superior to it in a number of parameters: - 15 times less exposure is required; - the ability to vary modes (incision, coagulation); - choice of power depending on the goal and tissue characteristics; - greater penetration depth of the bipolar electrode in the lower turbinate (higher efficiency in the treatment of nasal turbinate-dependent obstruction). Wolf Mann performs thermoreduction of the soft palate with three injections of 500-750 J each, the palatine tonsils with 2-4 injections each, sometimes the lateral folds and lateral walls of the pharynx and 6-7 injections of 1000 J in a diamond shape - into the root of the tongue. The total dose to the tongue is 6000-8000 J, the total dose is up to 12,000 J. Impact on all zones in one session, under general anesthesia. When selecting patients, a body mass index of no more than 27-30 and an AHI of up to 40 are taken into account. Results: a 19% decrease in AHI and a visual tissue reduction of 50% after one treatment session. In order to “find a common language” with the data of European studies, taking into account the specified parameters of Surgitron and the fact that 1 J = 1 W * 1 sec, we present the following tables. Table 1. Ellman-Surgitron power in various operating modes (W) Device scale value MODE I incision II incision + coagulation III coagulation 1 8 4 2 2 20 12 6 3 34 22 10 4 50 35 16 5 63 46 21 6 72 54 26 7 78 60 28 8 82 64 32 9 86 68 34 High 88 72 36 The biological effect of a radio wave depends on the amount of heat absorbed by the tissue and the size of the propagation halo. The absorbed heat is proportional not only to the power and exposure, but also to the thermal conductivity of the tissue, that is, mainly to its fluid content, so a creative clinical assessment of the situation during surgery is necessary: ??the degree of edema, blood filling, and moisture of the mucous membrane. No two noses and soft palates are the same, so a unified approach to choosing the exposure power seems wrong to us. We must monitor the color of the mucous membrane, preventing it from turning white, but when removing the bipolar electrode from the inferior turbinate in case of excessive blood filling, or elevated patient blood pressure, we hold the tip of the electrode for 2-4 seconds or increase the power by half a division until a punctate whitening of the mucous membrane at the site of the electrode exit from the anterior end (sometimes a click is heard): the mucous membrane seems to be welded and bleeding does not occur. Conducting experiments on In animal tissues, we noted that the heating area depends on the waveform. Thus, a partially rectified wave (coagulation) slowly spreads heat over a large area, while a fully rectified wave (incision + coagulation) produces a rapid tissue-reducing effect, as if concentrated heat was concentrated in a limited area along the electrode line. For 6 years, we have been using the "incision + coagulation" mode on the inferior turbinates, as opposed to the "coagulation" mode recommended by Ellman. According to Table 2, by selecting a power of 2.5-3 and an exposure of 10-15 seconds, we obtain the same amount of heat as Ellman, but this heat is not distributed slowly and widely, warming and "steaming" the entire inferior turbinate, which would result in prolonged postoperative edema, less hemostasis, and, possibly, affect the contractile function of the remaining vessels. Linearly, along the course of the electrodes, closing part of the capillaries, we leave intact mucosa and turbine bone, which decreases in volume literally before our eyes. Table 2. Radio wave reduction of the lower turbinates. Calculation of the amount of heat absorbed by the tissues depending on the exposure and mode of the Ellman-Surgitron device. Surgitron mode Power level (device scale) Power (W) Exposure (sec) Absorbed heat per injection (J) Total heat per 1 lower turbinate4 injections (J) III coagulation (Ellman) 3 10 10-15 100-150 400-600 4 16 10-15 160-240 640-960 II coagulation + incision (our experience) 2.5 17 10-15 170-255 680-1020 3 22 10-15 220-330 880-1320 4 35 10 350 1400 We have performed 862 radio wave thermoreductions of the inferior turbinates, of which 17 repeat procedures were required during the 5-year follow-up, which significantly exceeds the average. Patients were aged from 8 to 67 years, including those with cardiovascular pathology (2 patients after coronary artery bypass grafting (CABG), with obesity stages 1-3, vegetative-vascular dystonia and mentally labile. The operation was well tolerated, there was no bleeding. Patients left the office 10 minutes after the end of the procedure, breathing through the nose. There was no need for anterior nasal packing. All patients noted normalization of nasal breathing no more than two weeks after the operation (usually after 2-7 days). In a period of up to one month, mouth breathing at night ceased, the volume of snoring decreased or it disappeared completely. Radio wave for snoring! The first stage of snoring treatment is radio wave turbine - and Somnoplasty with 7-8 injections into the palate. After one month, we evaluate the result: simple snoring stops in 30% of cases. In this case, we perform subsequent somnoplasty sessions every 1.5-2 months until the patient is satisfied. No patient reported any pain after somnoplasty. According to indications, we perform uvulotomy and uvulopalatoplasty. I would like to emphasize the need to follow the technique: make vertical incisions in the palate upward by 0.5-1.5 cm, lateral to the base of the uvula by 0.2-1.0 cm on both sides, then cut off the uvula above its base and form a small "new" uvula. Making an incision excessively along the edges of the posterior arches, as if repeating their contours, as well as simply cutting off the uvula at its base with a loop can lead to cicatricial contraction of the edge of the soft palate and adhesion of the posterior arches to the lateral walls of the pharynx with Formation of nasopharyngostenosis. For uvulotomy, we use an insulated jigsaw electrode in the "cut + coagulation" mode, with a power of 3.5-4.0. For a thin palate, a universal cutting wire electrode in the same mode, with a power of 2.0-2.5, is convenient, coagulating, if necessary, with a small button electrode, which provides a gentle incision and a smaller whitening strip of no more than 1.5-2.0 mm. To avoid increasing the thickness of the palate and uvula, anesthesia is administered with five injections of 0.5% Marcaine or Scandonesta solution along the border with the hard palate, at the exit of the palatine nerves. With each repeat session, we take into account the structural features of the palate, uvula, and tonsils, gradually reducing their volume. We reduce the palatine tonsils in two ways: - for deep multiple lacunae, we coagulate them with a small button electrode in the "coagulation" mode, with a power of 3-3.5, Starting from the bottom of the lacunae, which gradually become shallower, the surrounding tissue is pulled around them. The mouths of the lacunae should not be closed immediately to avoid the formation of retention cysts; - with a smooth parenchymatous structure of the tonsils, we coagulate them with 2-4 injections into the thickness of a needle electrode or a "beak" electrode for somnoplasty, selecting the power and exposure individually, avoiding tissue blanching. We have performed somnoplasty - 212, reduction of the palatine tonsils - 41, uvulopalatoplasty and uvulotomy - 43. We perform somnoplasty with 7 injections, power 4, coagulation mode. The palate receives heat of 1100 - 1700 J, which corresponds to the technique of Professor W. Mann (see Table 3). Table 3. Calculation of the amount of heat absorbed by the tissue depending on the exposure and mode of the Ellman-Surgitron device Operating mode Method Power level (device scale) Power (W) Exposure (sec) Absorbed heat per 1 injection (J) Total heat on the palate (J) Coagulation Ellman 3.5 13 20 260 2 injections 520 Coagulation Our experience 4 16 10-15 160-240 7 injections 1120-1680 Coagulation Option 5 21 10 210 1470 Thus, radio wave reduction of soft tissues of the pharynx and nose in the treatment of snoring with the Ellman-Surgitron device appears to be low-traumatic, effective, and easily applicable in outpatient settings.