Efficacy of laser-assisted uvulopalatoplasty

Soft Palate Modification Using a Collagen Crosslinking Reagent for Equine Dorsal Displacement of the Soft Palate and Other Upper Airway Breathing Disorders

The mechanical properties of the soft palate can be associated with breathing abnormalities. Dorsal displacement of the soft palate (DDSP) is a naturally occurring equine soft palate disorder caused by displacement of the caudal edge of the soft palate. Snoring and a more serious, sometimes life-threatening, condition called obstructive sleep apnea (OSA) are forms of sleep-related breathing disorders in humans which may involve the soft palate. The goal of this study was to investigate the effect of injecting the protein crosslinker genipin into the soft palate to modify its mechanical properties for the treatment of equine DDSP with potential implications for the treatment of snoring and OSA in humans. Ex vivo experiments consisted of mechanical testing and a wind tunnel study to examine the effect of genipin on the mechanical properties, displacement, and vibration of equine soft palates. A pilot in vivo study was completed using DDSP and control horses to test the safety and effectiveness of injecting a genipin reagent into the soft palate. The wind tunnel testing demonstrated a greater than 50% decrease in transient deformation and a greater than 33% decrease in steady-state vibrations for all doses of genipin tested. Ultimate tensile stress, yield stress, and Young's modulus were higher in the genipin-treated distal soft palate specimens by 52%, 53%, and 63%, respectively. The pilot in vivo study showed a reduction of snoring loudness in all DDSP horses and elimination of DDSP in at least one of three horses. The difficulty of using a 1-meter-long endoscopic injection needle contributed to a consistent overinjection of the equine soft palates, causing excessive stretching (pillowing) and related degradation of the tissue. These ex vivo and in vivo results demonstrated reduced vibration amplitude and flaccidity and increased strength of genipin-treated soft palates, suggesting that genipin crosslinking could become an effective and safe treatment for soft palate related breathing abnormalities.

Morbidity and Mortality following Traditional Uvulectomy among Children Presenting to the Muhimbili National Hospital Emergency Department in Dar es Salaam, Tanzania

Background. Traditional uvulectomy is performed as a cultural ritual or purported medical remedy. We describe the associated emergency department (ED) presentations and outcomes. Methods. This was a subgroup analysis of a retrospective review of all pediatric visits to our ED in 2012. Trained abstracters recorded demographics, clinical presentations, and outcomes. Results. Complete data were available for 5540/5774 (96%) visits and 56 (1.0%, 95% CI: 0.7–1.3%) were related to recent uvulectomy, median age 1.3 years (interquartile range: 7 months–2 years) and 30 (54%) were male. Presenting complaints included cough (82%), fever (46%), and hematemesis (38%). Clinical findings included fever (54%), tachypnea (30%), and tachycardia (25%). 35 patients (63%, 95% CI: 49–75%) received intravenous antibiotics, 11 (20%, 95% CI: 10–32%) required blood transfusion, and 3 (5%, 95% CI: 1–15%) had surgical intervention. All were admitted to the hospital and 12 (21%, 95% CI: 12–34%) died. By comparison, 498 (9.1%, 95% CI: 8–10%) of the 5484 children presenting for reasons unrelated to uvulectomy died (p = 0.003). Conclusion. In our cohort, traditional uvulectomy was associated with significant morbidity and mortality. Emergency care providers should advocate for legal and public health interventions to eliminate this dangerous practice.

The surgical treatment of sleep-related upper airway obstruction

BACKGROUND

Obstructive sleep apnea (OSA) is a very common disorder among adults: the prevalence of mild OSA is 20%, and that of moderate or severe OSA is 6% to 7%. Simple snoring is even more common. Conservative treatments such as nocturnal ventilation therapy and oral appliances are successful as long as the patient actually uses them, but they do not eliminate the underlying obstruction of the upper airway.

METHOD

The relevant literature up to 2008 on the surgical treatment of OSA was selectively reviewed.

RESULTS

Five types of surgical treatment for OSA are available, each for its own indications: optimization of the nasal airway to support nasal ventilation therapy, (adeno-)tonsillectomy as first-line treatment for OSA in children, minimally invasive surgery for simple snoring and mild OSA, invasive surgery as first- and second-line treatment for mild OSA, and invasive multilevel surgery as second-line treatment of moderate to severe OSA that remains refractory to ventilation therapy.

CONCLUSION

Surgical treatment for OSA is appropriate for specific indications as a complement to the established conservative treatment methods.

[Guideline: Treatment of obstructive sleep apnea in adults]

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures

Continuous positive airway pressure (CPAP) for moderate and severe obstructive sleep apnoea (OSA), albeit effective management, is poorly tolerated. This study looks at the role of laser assisted uvulopalatoplasty (LAUP) in patients with moderate and severe OSA who would not tolerate CPAP. All subjects underwent dynamic sleep nasendoscopy to determine the anatomical level of obstruction and their suitability for the procedure. Twenty subjects were included. Pre-procedure mean apnoea-hypopnea index (AHI) was 47.9 per hour (21.3-101) and mean Epworth sleepiness score 15.6 (4-23). Post operative polysomnography at >or=4 months showed a 73% reduction in AHI to a mean of 12.9 per hour. Two subjects still required CPAP post procedure but both at reduced pressure. Epworth sleepiness questionnaire scores were reduced by a mean of 7.9 points. There was no confounding weight loss. The finding that LAUP offers an effective instrument to reduce the severity of OSA in patients intolerant of CPAP results disagree with the conclusion of the recent Cochrane Collabration review of surgery for OSA. We believe this is due to the careful selection of patients for LAUP based on the anatomical level of obstruction as opposed to random selection.

Complications of laser-assisted uvulopalatopharyngoplasty (LA-UPPP) and radiofrequency treatments of snoring and chronic nasal congestion: a 10-year review of 5,600 patients

PURPOSE

Recent laser and radiofrequency techniques for the treatment of snoring have provided improvements, but intraoperative and postoperative risks, complications, and long-term results have not been explored in a statistically large enough sample of patients. The goal of this article is to provide practitioners with important data and guidelines to help them in decision-making and prepare them to anticipate problems and recommend a systematic approach to avoid or treat complications.

PATIENTS AND METHODS

This investigation was a retrospective review of 5,600 cases, performed over a 10-year period by a single investigator, in a private practice setting. The data on complications were gathered from chart review as well as questionnaires filled out on each patient and by patient reports. The inclusion criteria for this review were: 1) patients with a history of chronic snoring or nasal congestion; 2) patients with an American Society of Anesthesiologists physical status classification (ASA) Classes I or II medical history; 3) patients provide a detailed preoperative snoring questionnaires; 4) patients provide informed consent; 5) patients were followed for a minimum of 2 years following surgery; 6) patients completed a comprehensive postoperative survey; 7) operative report stating the exact nature of any complications; 8) surgeons provided a clinical assessment; 9) sleep apnea reports if available; and 10) patient body mass index of less than 30 kg/m2.

RESULTS

Laser-assisted uvulopalatopharyngoplasty (LA-UPPP) was used for the treatment of snoring and mild obstructive sleep apnea in all cases; 40% of patients also had simultaneous nasal radioablation. No fatalities were recorded and fewer than 3% of patients had long-term complications. The most common intraoperative complication was bleeding, which occurred in 9.5% of patients.

CONCLUSION

Reducing the amount of tissue resected from the soft palate helped reduce or eliminate the common complications of traditional uvulopalatopharyngoplasty procedures. LA-UPPP and radioablation procedures are effective, safe, and can be carried out in an office setting equipped with anesthesia monitors and services. The complications associated with the procedure were rare and usually manageable.

Laser-assisted uvulopalatoplasty and tonsillectomy for the management of obstructive sleep apnea syndrome

OBJECTIVES/HYPOTHESIS

Laser-assisted uvulopalatoplasty (LAUP) is a widely accepted procedure for the management of snoring, but its role in the treatment of obstructive sleep apnea syndrome is currently unclear. The objective of the study was to evaluate the role of LAUP in treating moderate and severe obstructive sleep apnea syndrome.

STUDY DESIGN

Retrospective review of a surgical treatment protocol for obstructive sleep apnea syndrome.

METHODS

Between October 1993 and January 1999, 80 patients with moderate or severe obstructive sleep apnea syndrome and a significant component of retropalatal obstruction were treated with surgery at the Department of Otolaryngology at Northwestern University Medical School (Chicago, IL). Surgery consisted of LAUP with tonsillectomy (if tonsils were present) with the patient under general anesthesia or LAUP alone with local anesthesia (if the tonsils were absent). No patients received traditional uvulopalatopharyngoplasty. Sixty-four of the 80 patients underwent both preoperative and postoperative polysomnograms. Surgical "response" was defined as a 50% decrease in the apnea-hypopnea index (AHI) (the total number of apneic and hypopneic events per hour of sleep); surgical "cure" was defined as a 50% decrease in AHI and a final AHI of less than 20.

RESULTS

The surgical response rate was 59% (38 of 64 patients), and the surgical cure rate was 39% (25 of 64 patients). Twelve patients (18.8%) had a higher AHI after surgery. The AHI (mean +/- SD) changed significantly from 51.4 +/- 30.9 preoperatively to 26.3 +/- 20.8 on postoperative polysomnogram (P = 7.0 x 10-9). Laser-assisted uvulopalatoplasty alone was performed in 33 patients with a response rate of 61% and a cure rate of 42%. Laser-assisted uvulopalatoplasty with tonsillectomy was performed in 31 patients with a response rate of 58% and a cure rate of 35%. The overall incidence of nasopharyngeal insufficiency was 0%.

CONCLUSION

The results of the study suggested that LAUP with adjunctive tonsillectomy is an effective treatment for patients with obstructive sleep apnea syndrome and retropalatal obstruction with a lower complication rate than standard surgical therapy (uvulopalatopharyngoplasty).

Laser-assisted uvulopalatoplasty revisited

When performed correctly in a properly selected patient, LAUP provides good and lasting results in snoring improvement. A sleep study with snoring analysis helps in patient selection. Laser-assisted uvulopalatoplasty can be performed adequately in one sitting.

A randomized trial of laser-assisted uvulopalatoplasty in the treatment of mild obstructive sleep apnea

Laser-assisted uvulopalatoplasty (LAUP) is an outpatient surgical treatment for snoring and obstructive sleep apnea (OSA), but to date, no controlled trials have been published. Forty-five subjects with mild OSA (apnea/hypopnea index [AHI], 10-27 per hour) were randomized to LAUP or to no treatment (control group). The AHI post-LAUP was reduced by 21% overall and to 10 or less per hour in 5 of 21 subjects (24%). Four of 24 subjects in the control group (16.7%) had an AHI of 10 or less per hour at outcome. The AHI decreased with the LAUP compared with no change with the control group at outcome. Ten subjects (48%) reported significantly improved snoring after the LAUP. There was no improvement in excessive daytime sleepiness, but there was a small improvement in quality of life (unless side effects were included in the quality of life score). Side effects were common, but serious complications did not occur. LAUP surgery is effective in some subjects with mild OSA for the treatment of snoring, but the reduction in AHI and the level of symptomatic improvement were minor overall.

Sucralfate alleviating post-laser-assisted uvulopalatoplasty pain

Laser-assisted uvulopalatoplasty (LAUP) is an outpatient mode of treatment for snoring and perhaps for some mild cases of obstructive sleep apnea syndrome. LAUP results in severe throat pain that usually lasts for 8 to 14 days. Sucralfate adheres to proteins at the duodenal ulcer site, forming a protective coating against gastric acid, pepsin, and bile salts, that promotes healing. If a similar protective coating could be created at the area of LAUP trauma, morbidity may be diminished. Twenty-eight patients have undergone LAUP treatment-2 with mild obstructive sleep apnea syndrome and 26 with simple snoring. A block-randomized, single blind clinical study was performed. Sucralfate was administered in 14 patients (group A) every 6 hours for 15 days as a swish and swallow, whereas the other 14 patients (group B) received water for injection with a strawberry flavor as placebo with the same dosing. As a conclusion, sucralfate significantly lowered postoperative pain and the need for analgesic drug use as well as the total number of the days the patients needed to almost reach their normal diet quantity (> or = 80% of normal quantity).

Single-stage CO2 laser assisted uvuloplasty for treatment of snoring and mild obstructive sleep apnoea

PURPOSE

The purpose of this study was to describe a single-stage laser assisted uvuloplasty (uvulectomy) and to determine its effectiveness in treatment of snoring and mild obstructive sleep apnoea (OSA).

PATIENTS AND METHODS

All patients treated with laser assisted uvuloplasty in a 49-month period for snoring and/or mild OSA were studied. Frequency of snoring before and after surgery, loudness of snoring and postoperative discomfort were investigated. Patients were asked to evaluate change in daytime energy, sleep habits, missed days of work and also overall satisfaction following laser assisted uvuloplasty.

RESULTS

Thirty patients underwent a single-stage laser assisted uvuloplasty. A preoperative diagnosis of OSA was established in 19 patients, the remaining 11 patients were treated for snoring. There were no complications and only one patient required an additional stage. A questionnaire was completed by 18 patients (10 patients diagnosed with sleep apnoea, and eight patients with snoring only). Preoperatively the frequency of snoring averaged 9.3 cm on a visual analogue scale. Postoperatively there were 12 patients with either none or very minimal snoring and six patients who had an average score of 3.2. Loudness of snoring also decreased from an average of 5.4 to 2.5 cm. Postoperative discomfort averaged 1.1 cm. Improvement in sleep was noted by 16 patients and improved daytime energy was noted by 17 patients. Eleven patients reported that they missed at least one day of work postoperatively with an average of 3 days missed. Patient satisfaction was reported by 17 patients with only one stating that he was unsatisfied with the procedure.

CONCLUSIONS

Laser-assisted uvuloplasty (uvulectomy) is an effective surgical procedure for treatment of snoring and some types of OSA. A single-stage procedure appears to be effective and may further decrease the morbidity associated with this disease.

Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome

Cautery-assisted palatal stiffening operation (CAPSO) is a recently developed single office-based procedure performed with local anesthesia for the treatment of palatal snoring. A midline strip of soft palate mucosa is removed, and the wound is allowed to heal by secondary intention. The flaccid palate is stiffened, and palatal snoring ceases. This prospective study evaluated the ability of CAPSO to treat obstructive sleep apnea syndrome (OSAS). Twenty-five consecutive patients with OSAS underwent CAPSO. Responders were defined as patients who had a reduction in apnea-hypopnea index (AHI) of 50% or more and an AHI of 10 or less after surgery. By these strict criteria, 40% of patients were considered to have responded to CAPSO. Mean AHI improved from 25.1+/-12.9 to 16.6+/-15.0 (P = 0.010). The Epworth Sleepiness Scale, a subjective measure of daytime sleepiness, improved from 12.7+/-5.6 to 8.8+/-4.6 (P<0.001). These results indicate that CAPSO is as effective as other palatal surgeries in the management of OSAS.

Unpredictable results of laser assisted uvulopalatoplasty in the treatment of obstructive sleep apnoea

BACKGROUND

Laser assisted uvulopalatoplasty (LAUP) is increasingly offered for the treatment of obstructive sleep apnoea (OSA), although there is a lack of objective data to support its indications and efficacy. A study was undertaken to determine the treatment response to LAUP.

METHODS

Overnight polysomnography was performed before and at least three months after surgery in 44 consecutive patients with symptomatic mild to moderate OSA (apnoea + hypopnoea index (AHI) >10/h). Pharyngeal dimensions were measured by videoendoscopy (n = 11) and disease-specific quality of life, sleepiness and snoring frequency (n = 16) before and after surgery were determined in subgroups of patients. LAUP was performed under local anaesthesia as a one stage resection of the uvula and soft palate by one of two experienced otolaryngologists.

RESULTS

Twelve patients (27%) had a good response (AHI </=10/h after LAUP); four (9%) had a partial response (AHI </=50% of pre-LAUP value); 15 (34%) had a poor response (AHI >50% of pre-LAUP value); and 13 (30%) patients were worse (AHI >100% of pre-LAUP value). The velopharyngeal cross sectional area and anteroposterior diameter increased following LAUP (p<0.05). Quality of life indices improved significantly in all domains and sleepiness decreased. The snoring index did not decrease significantly. No preoperative anthropometric or videoendoscopic measures were predictive of a good response to LAUP. Patients who were worse after LAUP had milder baseline apnoea severity than those in the other response groups.

CONCLUSIONS

The treatment response to LAUP is variable and unpredictable, and only a few patients achieve a satisfactory response. There appears to be no relationship between subjective and objective measures of treatment efficacy.

Snoring Surgery: Which One is Best for You?

Excessive snoring is a common problem that is frequently treated surgically. In the early 1980s, uvulopalatopharyngoplasty was introduced to the United States as the first surgical treatment for excessive snoring. It remains in common use, but its limitations created an incentive to develop a procedure that is as effective, but safer and more economical. Several other surgical procedures for snoring were developed, including laser-assisted uvulopalatoplasty, palatal stiffening operations, and radiofrequency ablation. Each of these procedures has its own advantages and limitations; which procedure is the best treatment for excessive snoring is controversial. We present our experience with each of these procedures, along with a thorough review of the literature, to help the otolaryngologist determine which is the best snoring surgery for the individual patient.

Technologic advances in the treatment of obstructive sleep apnea syndrome

Among adult patients with obstructive sleep apnea syndrome (OSAS), adherence to continuous positive airway pressure (CPAP) treatment is approximately 40%, according to recent well-designed studies that evaluated outcomes other than adherence as a primary end point. This finding suggests the need for the improvement of the adult OSAS treatment approach, either by improving adherence to CPAP treatment or by developing effective alternatives to CPAP. Technologic advances have allowed for the development of new treatments for OSAS that include automatic CPAP and innovative airway procedures. Studies evaluating the application of these new technologies are reviewed. These technologic advances can be viewed as possible improvements over the existing treatment approach only if the risks and benefits of each new treatment are well understood by OSAS patients and their physicians.

Morphological assessment of the soft palate in habitual snoring using image analysis

OBJECTIVES

Define differences in palatal and uvular dimensions between habitual snorers and healthy nonsnoring control subjects. Document the changes in palatal configuration after different types of palatoplasty.

STUDY DESIGN

A prospective controlled clinical study was performed analyzing video recordings of the soft palate and oropharynx of 251 subjects (121 habitual snorers, 79 patients after laser-assisted uvulopalatoplasty ([LAUP], and 51 healthy volunteers).

METHODS

The recordings were captured using a rigid endoscope with a reference measure applied to the soft palate and a mark at the junction of the soft and hard palate. Four parameters were studied in the captured pictures after correction for the distortion deformity in fiberoptic endoscopic images: 1) length of soft palate, 2) length of uvula, 3) width of uvula, and 4) distance between posterior pillars.

RESULTS

Analysis showed that habitual snorers, compared with healthy volunteers have significantly increased soft palate length (P = .00001), increased uvula length (P = .0002) and width (P = .00001), and narrowed oropharyngeal isthmus (distance between the posterior pillars) (P = .04). In patients studied after LAUP, the length of the soft palate is significantly shorter (P = .00001) than in the preoperative cohort, and the oropharyngeal isthmus is significantly narrower (P = .00001). Moreover, this latter distance is significantly narrower (P = .00001) when compared with healthy volunteers.

CONCLUSIONS

Habitual snorers have a long soft palate, a long wide uvula, and a narrowed oropharyngeal isthmus. LAUP shortens and tightens the elongated palate and causes a further reduction in the space between the posterior pillars.

Objective benefit of laser palatoplasty for non-apnoeic snoring

Laser palatoplasty (LPP) is widely used for the treatment of non-apnoeic snoring, despite the lack of objective data supporting its use. We report measurements of snoring in a prospective study of LPP, and we compare the results with a previous study of uvulopalatopharyngoplasty (UPPP). Twenty patients with an apnoea/hypopnoea index < 20 h-1 underwent LPP for habitual snoring. Overnight sound recordings were compared before and 6 months after operation using three objective indices; L, (the level exceeded by the loudest 1% of sound), L5 (the level exceeded by the loudest 5% of sound) and P50 (% total sleep time above 50 dBA). The subjective impression of snoring severity (Wilcoxon test, P < 0.001), and objective indices L1 and P50 (t-test, P < 0.001) showed significant reductions after LPP. The mean change in L1 was 4.2 dBA, comparable to that we previously reported for UPPP, while P50 was reduced to less than one-third its preoperative value. No other sleep variables changed significantly following LPP. We conclude that LPP results in reduced snoring volume comparable to that following UPPP.