Palatal Implants for the Treatment of Snoring: Long-Term Results

Efficacy of pillar implants to reduce snoring and daytime sleepiness

OBJECTIVE

To measure the efficacy of pillar implants in reducing snoring.

MATERIALS AND METHODS

A total of 30 adult patients who underwent pillar implants were assessed preoperatively and at 1, 3, 6 and 12 months after the implantation. Improvement was measured using snoring frequency, visual analog scale for snoring loudness, and Epworth sleepiness scale for daytime sleepiness.

RESULTS

The mean snoring frequency, loudness and Epworth score were reduced from 6.9, 9.2 and 7.4 at the baseline to 5, 5.9 and 5.6, respectively, at 12 months postoperatively (all p < 0.03). The partial implant extrusion rate was 6.7%.

CONCLUSION

We suggest that a pillar implant procedure should be considered before proceeding to more morbid surgeries in patients with snoring and daytime sleepiness.

The palatal septal cartilage implantation for snoring and obstructive sleep apnea

OBJECTIVE

Patients with snoring and obstructive sleep apnea frequently have nasal and palatal obstruction. The objective of this study was to investigate the safety and feasibility of a palatal septal cartilage implant (SCI) for snoring and obstructive sleep apnea.

METHODS

This was a preliminary study of 10 consecutive patients who were enrolled retrospectively from electronic charts. The patients had undergone a single-stage operation including septoturbinoplasty and palatal SCI at a tertiary referral hospital. After nasal surgery, the harvested cartilage was prepared and trimmed into strips for palatal implantation. Key procedures of palatal SCI include vertical tunneling of the midline and paramedian soft palate, insertion of the septal cartilage strips, and fixation suture of the implants. The primary outcome measures were adverse events, including implant extrusion, infection, bleeding, velopharyngeal insufficiency and globus symptoms, assessed by the Glasgow-Edinburgh Throat Scale (GETS) questionnaire (10-item, 8-grade [0-7] Likert scale). Secondary outcomes were subjective snoring loudness (visual analogue scale, VAS), excessive daytime sleepiness (Epworth sleepiness scale, ESS) and objective apnea-hypopnea index. All patients were followed up for at least 1 year.

RESULTS

None of the aforementioned adverse events were noted during the one-year follow-up. Among the ten items of the GETS, the median score of nine items was 0, and the median score of the total GETS was 2.0, which was classified as "asymptomatic". The snoring loudness improved significantly from 8.0 points (IQR 8.0-9.0) preoperation to 4.0 points (IQR 2.5-6.0) at 3 months postoperation and 4.5 points (IQR 3.3-6.0) at 1 year postoperation (P=0.002 and P=0.002, respectively). The ESS score improved significantly from 11.5 points (IQR 8.3-18.5) preoperation to 8.0 points (IQR 6.3-10.8) at 3 months postoperation and 8.5 points (IQR 6.3-10.8) at 1 year postoperation (P=0.004 and P=0.004, respectively). The apnea-hypopnea index significantly decreased from 54.7 (IQR 23.4-62.8) to 20.5 (IQR 14.7-45.6) (P=0.047) in patients with a lower tongue position (modified Mallampati class≤II; n=7).

CONCLUSION

Palatal SCI is a safe and feasible procedure. The advantages include providing implants of tailor-made length, biocompatible autologous cartilage and no need for extra-payment for the implant material. By using the SCI procedure, both nasal obstruction and sleep-disordered breathing can be managed in a single-stage operation. The long-term effectiveness of SCI deserves further research.

Extended follow-up of palatal implants for OSA treatment

Objective

Evaluate long-term safety and outcomes of palatal implants for patients with mild to moderate obstructive sleep apnea (OSA).

Study Design and Setting

Continuation of a prospective case series of patients with palatal implants. Polysomnography, daytime sleepiness, and snoring intensity were measured at baseline, 90 days, and extended follow-up.

Results

Twenty-two (42%) patients from the previous study were followed for a median of 435.5 days. Thirteen were classified as responders, based on their 90-day evaluation. 76.9% of initial responders maintained improvements in apnea-hypopnea index (AHI), daytime sleepiness, and snoring at extended follow-up. Nine patients were initial nonresponders for AHI and daytime sleepiness and remained unchanged at extended follow-up. However, snoring for these nine patients initially improved, and the improvement continued through extended follow-up.

Conclusion

Initial response or nonresponse to palatal implants remains stable over an extended period. The generalizability of these results is unknown because of significant loss to follow-up.

Significance

Study results report safety and beneficial long-term outcomes of palatal implants for mild to moderate OSA treatment in selected patients.

Effect of the Pillar implant on snoring and mild obstructive sleep apnea: A multicenter study in Korea

OBJECTIVES/HYPOTHESIS

The effect of the Pillar implant on mild sleep-disordered breathing (SDB) has been assessed in various studies. However, most of these were conducted among a non-Asian population at a single institution. Therefore, the aim of this study was to prospectively evaluate the efficacy of the Pillar implant in Asian patients with simple snoring and mild obstructive sleep apnea (OSA) at multiple centers.

STUDY DESIGN

Multicenter prospective clinical trials.

METHODS

This study included consecutive subjects with simple snoring or mild OSA. We examined subjective symptoms (snoring intensity, frequency, witnessed apnea, and daytime sleepiness) and objective snoring and respiratory parameters (snoring duration [proportion of sleep while snoring louder than 50 dB], snoring loudness, apnea-hypopnea index, respiratory disturbance index, minimum arterial oxygen saturation, and oxygen desaturation index ≥ 4%) at 3 to 6 months after surgery. Adverse events were also investigated.

RESULTS

Twenty-nine subjects with mild SDB completed the study. Whole group analysis found significant improvements in various subjective symptoms, but not in the objective snoring and respiratory parameters. A subgroup analysis of subjects with mild OSA (n = 11) found significant alleviation in various subjective symptoms, apnea-hypopnea index, respiratory disturbance index, and oxygen desaturation index ≥ 4%. No major complication related to surgery was observed, and most minor adverse effects were resolved without morbidity.

CONCLUSIONS

In selected Korean patients, the Pillar implant significantly improved not only subjective symptoms of mild SDB but also respiratory disturbances in mild OSA.

LEVEL OF EVIDENCE

2b.

Three-year follow-up of palatal implants for the treatment of snoring

CONCLUSIONS

The safety of treatment with palatal implants remains high 3 years after the procedure. The implant extrusion rate decreases over time. Additional surgery to the palate is safe. The presence of the implants seems important in sustaining efficacy past 1 year.

OBJECTIVES

To investigate long-term safety and treatment results of palatal implants for treatment of snoring.

METHODS

A prospective clinical non-randomized trial of 55 patients with primary snoring followed over a period of 3 years.

RESULTS

No major adverse events were observed. Eleven of the 55 patients (20%) experienced implant extrusions, 8 during the first year, 3 in the second, and none in the third year. Twenty-six patients (47.3%) had additional procedures past 1 year. Only one post-implant surgery caused an extrusion. The success defined as no additional surgery followed by endpoint satisfaction rate was 34.6%. For patients with implants intact it was 41.5% (17/41) at 3 years, significantly better than for those who experienced loss of implants.

Does the length of uvula affect the palatal implant outcome in the management of habitual snoring?

OBJECTIVES/HYPOTHESIS

To evaluate the impact of the uvular length on the efficacy of palatal implants in primary snoring.

STUDY DESIGN

Prospective case series, tertiary hospital, snoring and respiratory sleep disorders center.

METHODS

Forty subjects with inserted palatal implants and diagnoses of primary snoring were included. All met the inclusion criteria of age >18 years, body mass index <30, apnea-hypopnea index <5, tonsil grade <3, soft-palate length >25 mm, and Friedman tongue position <3 following clinical, endoscopic, and polysomnographic evaluation. Epworth sleepiness scale (ESS) and the snoring-intensity visual analogue scale (VAS) were recorded before and 9 months after the implant. Four subjects with extruded implants were excluded; the remaining 36 subjects were divided into two groups, Group I and Group II, with uvular lengths of ≤15 mm and >15 mm, respectively. The study assessed and compared subjective outcome measures including the partner's satisfaction (PS), partner's reported improvement (PRI), 50% VAS and ESS reduction, and subjective success (SS) defined as 50% VAS reduction. The Student t test, χ(2) test, and logistic regression models were used for statistical evaluation.

RESULTS

SS (50% VAS reduction), PS, PRI, and 50% ESS reduction were significantly higher in Group I (P < .001, P = .0257, P = .027, P < .001). The overall SS, PRI, PS, and 50% ESS reduction were 33%, 78%, 50%, and 50%, respectively. The uvular length was found to be the determinant factor of SS (P = .005; odds ratio = 0.75), PRI (P = .039; odds ratio = 0.83), and 50% ESS reduction (P = .038; odds ratio: 0.84) following implant insertion through stepwise logistic regression analysis.

CONCLUSIONS

Excess uvular length (>15 mm) is an important anatomic feature decreasing the efficacy of palatal implants in snoring, and additional measures, such as uvulectomy, should be considered simultaneously for better outcomes (level 4).

Surgical options for the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.

Reconstruction of airway soft tissues in obstructive sleep apnea

Surgery for obstructive sleep apnea is multimodal. Procedures and aims of treatment vary. Surgery, medical devices, and medical therapy each may contribute to individualized patient care. There is no single procedure or intervention that "cures" upper airway obstruction. Treatment varies as the disease varies. In addition, surgical treatment varies because the level of obstruction and influence on air flow occurs at multiple levels and from many structures. This article is not intended as a critical assessment of surgical outcomes but rather focuses on airway structures and the nature of the procedures applied to influence them.

Uvulopalatopharyngoplasty funded by the Australian government's Medicare scheme (1995-2007)

Objective: To describe the provision, through the Australian state-funded Medicare system, of uvulopalatopharyngoplasty (UPPP) and its laser-assisted variation (LAUP) to the population of Australia between 1995 and 2007.

Study Design: Case series using a comprehensive national administrative database.

Setting: The Commonwealth of Australia.

Subjects and Methods: Subjects comprised the population of Australia. The raw numbers of procedures, reimbursement amounts in Australian dollars, and per capita adjustment nationwide and in each state/territory for UPPP and LAUP for each calendar year from 1995 to 2007 were downloaded from a publicly accessible database run by Medicare.

Results: The Australian federal government paid AUD 8.2 million for 19,534 UPPP procedures and AUD 1.1 million for 3270 LAUP procedures in the calendar years 1995 to 2007, inclusive. There is substantive variability between states in provision. Over time, provision of UPPP has declined slightly compared with population growth and overall Medicare provision. LAUP provision has declined markedly.

Conclusion: Provision of UPPP under Medicare in Australia has declined slowly relative to population growth and overall growth in Medicare per capita provision. Laser-assisted UPPP (LAUP) has steadily declined and is now rarely used compared with the peak in its provision in the mid 1990s.

Do palatal implants really reduce snoring in long-term follow-up?

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy of palatal implants in primary snoring patients and to determine the long-term results.

STUDY DESIGN

Retrospective clinical trial.

METHODS

Twenty-one adult primary snorers treated with palatal implants were reviewed. Apnea-hypopnea indexes of all the patients were <5. Patients and their partners were evaluated together at 0, 30, and 90 days and at 6, 12, and 18 months. The partners' visual analog scale (VAS) for snoring intensity and the patients' overall satisfaction, along with the Epworth sleepiness scale, were used for assessments.

RESULTS

The mean VAS score was reduced from 9.1 +/- 1.1 to 5.4 +/- 2.7 at the 3rd month, and to 5.1 +/- 3.15 at the 1st year (P < .05). At the 6th month, VAS scores of snoring intensity were reduced >50% in 13 of the patients (61.9%) and 52.3% (n = 11) at the 12th month. Eleven successfully treated patients and their partners were revisited at the 18th month, and both recommended the implant to others. The patient satisfaction rate was over 80% in 14 of the patients after 1 year. The mean ESS scores decreased from 7.8 to 5.5 after 180 days (P < .05). There was a strong correlation between low oxygen desaturation index and treatment success (coefficient, 0.779; P < .001). There were no postprocedure complications, such as bleeding, infection, and extrusion.

CONCLUSIONS

In primary snoring patients, pillar implant is a safe and easy single procedure. At the 18th-month follow-up, partners' VAS score improvement was 53%, along with 80% patient satisfaction.

Effectiveness of Pillar palatal implants for snoring management

Objective: Determine patient factors associated with the success and complications of using the Pillar palatal implants for snoring management.

Study Design: Retrospective series of 79 consecutive adult patients receiving Pillar implants for snoring management between January 2005 and December 2007. Multiple regression analysis was used to determine factors associated with initial and final bed partner satisfaction with the snoring result, and factors associated with Pillar-related complications.

Results: A total of 64 of 79 (81%) bed partners reported snoring improvement in patients after initial Pillar implantation; however, only 31 (39%) were satisfied with the level of reduction. Following secondary procedures, the number of satisfied bed partners improved to 52 (66%). Factors associated with final bed partner satisfaction included lower initial apnea-hypopnea index (AHI) ( P = 0.029), Friedman tongue position I or II ( P = 0.008), and shorter follow-up time ( P = 0.001). Sixteen patients (20%) experienced procedure-related complications. Factors associated with Pillar complications included female gender ( P = 0.001) and placement under general anesthesia ( P = 0.009).

Conclusions: Initial AHI values and tongue position scores are important determinants of final snoring success. Pillar implants placed in women and under general anesthesia may have a higher risk of poor placement and extrusion.

Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome

OBJECTIVE

Randomized, double-blinded, placebo-controlled, clinical trial to determine the effectiveness of palatal implants for treatment of mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN AND SETTING

Sixty-two non-obese adults with history of snoring, daytime sleepiness, and mild/moderate OSAHS, were randomized to receive palatal implants (n = 31) or placebo procedure (n = 31). Complete follow-up including quality of life (QOL, SF-36), snoring visual analog scale (VAS), and Epworth Sleepiness Scale (ESS) data were obtained in 62 patients. Seven patients refused follow-up polysomnography for a total of 55 patients (29 implant and 26 placebo).

RESULTS

The treatment group (change in score of -7.9 +/- 7.7) was significantly improved compared with the placebo group (change in score of 0.9 +/- 4.3) for apnea/hypopnea index (AHI) (P < 0.0001), QOL, SF-36 (P < 0.0001), snoring VAS (P < 0.0001), and ESS (P = 0.0002).

CONCLUSIONS

Palatal implants improve AHI, QOL, snoring intensity, and daytime sleepiness for selected patients with mild/moderate OSAHS.

Additional palatal implants for refractory snoring

OBJECTIVE

To evaluate safety and efficacy of additional palatal implants for snoring treatment.

STUDY DESIGN AND SETTING

A prospective case series at two clinical sites in an office setting. Patients who did not have an acceptable reduction in snoring intensity after an initial 3 implant procedure received additional implants. Bed partners rated snoring intensity on a 10 cm visual analog scale (VAS) at baseline and 90 days postprocedure.

RESULTS

Snoring intensity VAS decreased significantly from 6.4 +/- 2.3 to 4.6 +/- 2.9 (P < 0.01) for patients who received an additional fourth implant, and to 4.1 +/- 2.8 after the 5th implant (P<0.01). Epworth sleepiness scale scores also decreased significantly for patients who received additional fourth or fifth implants. There were no adverse events.

CONCLUSIONS

Additional palatal implants for snoring treatment were safe and effective in this case series.

SIGNIFICANCE

Additional implants may offer relief for snorers not responding to the initial 3 implant procedure.

One-year results: palatal implants for the treatment of obstructive sleep apnea

OBJECTIVE

To evaluate long-term effectiveness of palatal implants for treatment of mild to moderate obstructive sleep apnea (OSA).

STUDY DESIGN

A prospective study of 26 referred patients with a pretreatment apnea-hypopnea index (AHI) of 10 to 30 and a body mass index of < or =30, representing an extended follow-up of a subset of 41 patients enrolled in previous short-term trials.

RESULTS

Twenty-one of 26 patients (80.8%) experienced a decrease in AHI. Fifteen of 26 patients (57.7%) had a follow-up AHI <10 at 1 year, whereas 13 patients (50%) had a 50% or greater reduction to an AHI <10 at 1 year. Mean AHI was reduced from 16.5 +/- 4.5 at baseline to 12.5 +/- 10.5 at 3 months (P < 0.014) and to 12.3 +/- 12.7 at 1 year (P < 0.019).

CONCLUSIONS

Patients initially responding to palatal implants with improved AHI maintained improvement through long-term follow-up at 1 year.

Snoring: a critical analysis of current treatment modalities. Does anything really work?

PURPOSE OF REVIEW

To determine the current options available for the treatment of snoring in the symptomatic patient, as this can be troublesome not only for the patient, but also the patient's bed partner. These include both surgical and non-surgical measures.

RECENT FINDINGS

The main themes that will be addressed include over-the-counter snoring aids, oral appliances, and surgical options. Surgical options include uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, radiofrequency thermal ablation therapy, injection snoreplasty, and palatal implants.

SUMMARY

There are many alternatives available to treat snoring. None of these methods are without their negative aspects, therefore there is still a great need for further research and long-term follow-up studies to determine the best method. The final consensus of this review is that surgical options yield the best results, but these are often surgeon dependent, and none are free of relapses in snoring. Some options are also thought to offer several advantages, including less peri-operative pain and recovery time, less expense, and the ability to be performed in the office. The palatal implant system and radiofrequency thermal ablation appear to have relatively good outcomes, with little postoperative pain and relatively self-limited complications. They also have the convenience of an in-office procedure and less expense.

Palatal stiffening after failed uvulopalatopharyngoplasty with the Pillar Implant System

OBJECTIVE/HYPOTHESIS

The objective of this study was to measure subjective and objective improvement after palatal stiffening in patients after uvulopalatopharyngoplasty (UPPP) who were experiencing persistence or recurrence of snoring with or without daytime sleepiness symptoms.

STUDY DESIGN

The authors conducted a prospective, nonrandomized study of 26 patients after UPPP who underwent the Pillar Implant Technique (PIT) as a revision procedure.

METHODS

Patients were selected to undergo revision PIT if they presented with recurrence or persistence of snoring after UPPP. Patients had mild or moderate obstructive sleep apnea-hypopnea syndrome (OSAHS) (apnea-hypopnea index [AHI] >5 and < or =40), persistent retropalatal obstruction, and a residual palate > or =2 cm. Some patients experienced daytime somnolence as well. Patients with severe OSAHS (AHI > or =40), Friedman anatomic stage IV, and/or nasopharyngeal stenosis were excluded. Pre-/postoperative snoring levels, Epworth Sleepiness Scale (ESS), SF-36v2 Quality of Life (QOL) questionnaires, and polysomnograms were obtained.

RESULTS

We completed data on 23 patients. Postoperative snoring levels (3.4 +/- 1.8) and ESS (8.7 +/- 1.8) significantly improved (P < .0001) compared with preoperative values (8.7 +/- 1.8 and 13.2 +/- 2.9). A total of 73.9% of patients improved subjectively. Seven of eight SF-36v2 QOL domains showed significant improvement (P < .05). Postoperative AHI and minimum oxygen saturation also improved significantly (P < .05). Objective cure was only achieved in 21.7% of patients.

CONCLUSIONS

Revision PIT is effective in achieving subjective improvement of recurrent symptoms after UPPP. Objective cure was only obtained in 21.7% of patients. As a result of the safety and low morbidity of the procedure, it is an alternative to improve symptoms, especially snoring, in patients not willing to accept continuous positive airway pressure permanently or patients who refuse revision surgery.

Snoring noise pollution—the need for objective quantification of annoyance, regulatory guidelines and mandatory therapy for snoring

Habitual snoring without episodes of apnea or hypoventilation and without respiratory related arousals is considered to be annoying and without any need for treatment. However, studies seem to suggest an enormous psychosocial impact of annoyance for the bed partner. Apart from subjective questionnaires there still exists no generally accepted mode of measurement that can describe snoring objectively. We therefore adapted methods developed for environmental medicine and established a new snore score using psycho-acoustic parameters. For quantification of snoring noise we conducted nocturnal measurements in 19 habitual snorers. Free-field snore sounds were acquired with two low-cost non-contact microphones and transferred to a PC (sampling frequency 11 kHz). The data were recorded, analysed and stored automatically using a MATLAB script. Following the analysis of sound characteristics and levels, the score was computed from relevant parameters containing the rating level (L(R)), maximum level, two percentile levels for frequent maxima (L(5)S; L(1)) and snoring time. The determined values substantially exceeded the prescribed limits defined by WHO noise guidelines, and mainly affected the equivalent continuous sound exposure level, rating level and the immission standard values of brief noise peaks, whose maximum was exceeded by up to 32 dB(A). The Berlin snore score illustrated the objective acoustic annoyance on a scale from 0 to 100. It allows inter-individual comparison and objectifies the need for therapy. The clinical applicability of evaluating the reduction of snoring after surgical therapy is discussed exemplarily. The presented measuring method was found to be suitable for quantifying snoring noise and can be easily integrated into existing polysomnographic applications. In the case of habitual snoring with objective evidence of psychosocially disturbing acoustic annoyance, health fund providers should assume the costs of mandatory medical therapy.