Professional Documents
Culture Documents
40 (2007) 891–901
associated with the snoring. The uvulopalatal flap [1] is a variation that has
the potential to be reversed if needed; this reversal is rarely indicated.
In one review of eight studies of UPPP for snoring [2], 29.8% of patients
had no snoring and 43.1% had reduced snoring, for an overall ‘‘success’’
rate of 72.9%.
Procedures that come closest to achieving this ideal are discussed in the
following sections.
Injection snoreplasty
This consists of injection of a sclerosing solution into the palate to
produce scarring and soft palate stiffening [4]. The resultant stiffening or
shortening of the palate prevents excessive vibration of the posterior edge
of the soft palate, thought to produce the snoring noise in the majority of
cases.
This procedure and the soft palate tightening procedure can be per-
formed in the office under local anesthesia, without the need for sedation.
Postoperative pain is usually mild and the complications minor. The cost
of palate injection is extremely low; the cost of RF treatment is higher,
and may require purchase of a disposable RF needle electrode, an additional
expense. In addition, an RF generator is needed, and this cost must be am-
ortized, adding to the expense. Over time, the effectiveness of the RF treat-
ment decreases, and it may need to be repeated; the same will probably
prove true for injection snoreplasty.
Uvulectomy
Uvulectomy in the office using an RF snare, standard cautery, or CO2
laser appears to be similarly effective, but has greater pain in the postoper-
ative period, lasting a week or more in most patients [5]. The same is true for
extended uvulectomy procedures, such as UPP, that remove more of the free
edge of the soft palate. These procedures may have the long-term complaint
of a feeling of ‘‘mucous’’ or dryness on the nasopharynx side of the palate
border; procedures that spare the free edge of the palate do not produce
this symptom.
Pillar procedure
Stiffening the soft palate by insertion of three or more small barbed im-
plants has been found to decrease snoring [7]. It can be performed quickly in
the office under local anesthesia. The major complication is postinsertion ex-
trusion. One disadvantage is the relatively high cost of the implants.
makes sense that opening an obstructed nose should make the patient feel
better.
A trial of a device to open the nasal valves at night can be used in the
same way as a nasal spray to shrink the turbinates. They can be used in com-
bination to determine if collapse of the valves, turbinate engorgement, or
both are contributing to nocturnal nasal obstruction, which results in
snoring.
Several devices are available, sold over the counter, to open the nasal
valves at night. Breathe Right strips (GlaxoSmithKline, Pittsburgh, Pennsyl-
vania) taped to the lower nose at night are the best known, and some data
indicate that they help [10]. Such devices can be used indefinitely, or an op-
eration to open the nasal valve area can be performed [11], either separately
or in combination with inferior turbinate reduction or septoplasty.
Evaluation of snoring
Unfortunately, the nature of snoring is such that it is almost impossible
for us to have hopes for an ideal snoring operation. There are three reasons
for this, two which we can address and attempt to solve; the third is more
difficult. The first is a diagnostic issue as to the exact site of the sound pro-
duced by the snorer. It is generally assumed that the majority of snoring
comes from vibration of the soft palate free edge. The data for this are
not as clear as we would like. Certainly, if the loud snoring that regularly
accompanies OSA and upper airway resistance syndrome (UARS) is caused
by the palate, it would appear logical that nocturnal airway obstruction has
the same cause. This is usually not the case, with the tongue base or hypo-
pharnx being a major component, with or without palate level obstruction.
The nose can produce noise at night because of narrowing, and possibly the
presence of thick mucus. This nasal snoring group are the patients whose
snoring improves with nasal surgery. In addition, nasal obstruction leads
to mouth breathing, and the presence of an open mouth during sleep in-
creases the sound intensity of the snoring. Although it is possible to snore
with the mouth shut, the sound levels achieved are not as great.
Some snorers snore during the exhalation stage rather than while inhaling,
and some snore on both inhalation and exhalation; the significance of this in
regard to treatment is unclear. Certainly, there are snorers in whom the
tongue is a component of the snoring noise, and this may be the sole compo-
nent after the palate has been shortened or tightened. Basically, our inability
to identify the site or sites of the snoring noise hampers our ability to provide
an appropriate operation. To operate on the palate of a snorer whose tongue
is the major reason for the snoring makes no sense, but is probably done all
the time.
The second problem is that even if we are sure that the snoring noise is
coming from soft palate vibration, we do not know how much palate re-
moval or tightening is required in a given case to totally eliminate the
TREATMENT OF SLEEP APNEA PATIENTS 895
Diagnosis of site
In the author’s opinion, the best objective test to determine the site of ob-
struction is multilevel pressure measurements during sleep [14]. This is not
routinely performed for a number of reasons. Sleep laboratories have no in-
centive to do such testing, because nasal CPAP corrects obstruction at all
levels; site of obstruction determination is of interest primarily to the sur-
geon. Current reimbursement schemes would need to be modified to pay
for such additional testing; sleep laboratories would need to be incentivised
by surgeons to perform such tests, or the surgeons would need to support
specialized testing systems that provide these data. Esophageal pressure
measurements during sleep have allowed us to diagnose UARS; a single
pressure measurement in the upper esophagus reflects the abnormally nega-
tive interthoracic pressure needed for inspiration during sleep. A similar test
using multilevel pressure sensors would provide us with a measurement of
obstruction at the palate and tongue base.
TREATMENT OF SLEEP APNEA PATIENTS 897
The use of artificial sleep using intravenous medications while the sur-
geon looks at the potential areas of obstruction with a fiberoptic endoscope
(sleep endoscopy) is used routinely in several centers outside of the United
States. It is expensive and time-consuming, unless performed at the time
of surgery for OSA. This is not routinely done in the United States, and
there are questions as to whether sleep produced by intravenous drugs is
the same as normal sleep. Volume CT and MRI evaluations during artificial
sleep also have limitations, with cost and risks similar to sleep endoscopy.
in OSA. The morbidly obese (BMIO33) are not good UPPP candidates
either.
Sleep endoscopy should provide improved UPPP results, because it can
better identify the sole or significant soft palate etiology OSA patients
who are the best candidates. In general, this is true; however, the difference
is not as much as desired [16]. Why is this? Although the answer is not
totally clear, the author believes it is twofold: (1) analysis, even with this
excellent method, is still a work in progress, and (2) UPPP, as usually
performed, does not adequately correct palate obstruction in a sizeable per-
centage of cases. More aggressive approaches to palatal shortening may pro-
vide better postoperative results, but have longer recovery periods and are
more involved. These include palatal Z-plasty and transpalatal advancement
pharyngoplasty [17,18].
Combining preoperative sleep endoscopy or multilevel pressure measure-
ments to confirm a palatal site of obstruction and a more aggressive palate
shortening procedure should result in improved surgical results for OSA pa-
tients who have a palate cause. At this time, UPPP should not be the sole
surgical treatment for the usual case of OSAdit is not good enough.
Tonsillectomy
In children, tonsillectomy and adenoidectomy have provided successful
treatment of OSA in the majority of patients, because the obstruction is usu-
ally caused by enlarged tonsils or adenoids [2]. In adults, the presence of
large tonsils makes it more likely that a UPPP and tonsillectomy will be
successful.
Radiofrequency
The success of multiple RF treatments to the tongue base, in a review of
11 series, ranges from 20% to 83%, using the usual surgical success criteria
[19]. The usual number of insertions of the RF needle is four at one time,
750 J each site. Multiple sessions, weeks apart, are required. An average
of 5.5 sessions was required in one series to produce a success rate of
TREATMENT OF SLEEP APNEA PATIENTS 899
46.7% [20]. This is not adequate for the amount of treatments required, in
the author’s opinion. Other RF protocols are being evaluated and show
promise.
Geniotubercle advancement
In combination with UPPP, geniotubercle advancement (GTA) produces
a success rate of 39% to 70% [19].
Hyoid suspension/advancement
Again, usually used in combination with UPPP, and in some series, GTA.
By itself (but with UPPP) it appears to provide little advantage over UPPP
alone in the author’s experience (17% success) [21]. Others have found bet-
ter results (53.3%) [22].The latter study used preoperative sleep endoscopy
to better define the sites of obstruction. When combined with a GTA, there
may be an advantage over a GTA alone, but this is not clear.
Maxillomandibular advancement
Maxillomandibular advancement (MMA), the current ‘‘gold standard’’
for OSA, has a success rate of 90% or greater [23], but it is technically de-
manding and has substantial morbidity and expense.
Tracheotomy
Still very effective, but hard to convince patients to accept the side effects.
Other
Bariatric surgery can be effective in reducing the RDI in grossly obese
patients. Mandibular distraction in children who have poor mandibular
development may be curative in selected cases. The use of a dental splint
to further advance the lower jaw after failure of a GTA, repose, or RF
tongue procedure may provide success after failure of the surgical proce-
dure [24].
900 GOODE
Summary
In summary, we are in need of better methods of diagnosing the sites of
obstruction before surgery, and also better surgical procedures and combi-
nations of procedures to provide successful outcomes of greater than 80%
with minimal morbidity. Procedures that correct retrolingual obstruction
are particularly needed. The author is optimistic that this will occur!
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