Temperature-controlled radiofrequency tissue volume reduction of the soft palate (somnoplasty) in the treatment of habitual snoring: results of a European multicenter trial

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Treatment of sleep disordered breathing relapse after surgery

This narrative review provides a general overview of the management of relapses after surgery for the treatment of sleep disordered breathing. This clinical scenario represents a challenging field, but fortunately several therapeutic options are included in sleep surgeons’ armamentarium. Each therapeutic modality is described in detail in a dedicated section.

Radiofrequency Soft Palate Procedure in Snoring: Influence of Energy Delivered

OBJECTIVE: We conducted a retrospective study to evaluate the influence of amount of energy delivered during radiofrequency procedure for soft palate reduction in snoring, to improve the cure rate.

METHODS: Consecutive patients with chronic disruptive snoring presenting to our department were successively treated in an outpatient procedure. A visual analog scale was used to assess the severity of snoring by the bed partner and the pain by the patient, before treatment and after each treatment session. The soft palate was divided into 3 treatment sites: middle, lateral right, and lateral left. Any mucosal injury of the soft palate was classified as a complication.

RESULTS: Forty-3 patients were classified into 2 groups according to energy assignment. The total amount of energy delivered was 1250 J in group 1 (n = 15) and 1500 J in group 2 (n = 28). Energy was predominantly distributed in the middle of the soft palate in group 1 (550 J) and group 2 (800 J). After each treatment session, the 1500-J delivery of radiofrequency energy (total per session) led to a better snoring grading reduction in comparison with the 1250-J delivery with a significant difference after 2 treatment sessions ( P < 0.05). The mean pain score and the incidence rate of complications per treatment were not statistically different in comparing both groups.

CONCLUSION: Better snoring scores can be expected by increasing radiofrequency energy applied to the soft palate. Further randomized long-term investigations are required to confirm that the cure rate can be improved when increasing energy with a suitable distribution and good clinical tolerance.

Palatal implants for primary snoring: Short-term results of a new minimally invasive surgical technique

OBJECTIVE:

To determine the safety and efficacy of a new soft palate implant procedure for the reduction of snoring.

STUDY DESIGN AND SETTING:

Fifteen healthy patients with primary snoring due to palatal flutter were enrolled into this prospective study after clinical and endoscopic examination and polysomnography. The average age of the patients was 41.2 ± 8.6 years with a body mass index of 26.2 ± 2.5 kg/m 2 . The Anti-Snoring Device consists of a delivery tool with a cylindrical implant of braided polyester filaments. Under local anesthesia, three implants intended for permanent implantation were placed into the soft palate. Snoring-related symptoms were assessed by visual analogue scales (VAS), polysomnography, and the SNAP system at baseline and 90 days postoperatively.

RESULTS:

All implants were placed without complications. Only minor discomfort was reported in four cases within the first three days postprocedure. At the 90-day follow-up snoring was reduced from 7.3 ± 1.6 to 2.5 ± 2.1 (VAS, P < 0.01) and from 347 ± 239 to 264 ± 168 snoring sounds/hour (SNAP, P > 0.05). Polysomnography did not show any deterioration of sleep or breathing. Speech, swallowing, and taste were unchanged.

CONCLUSION:

The Anti-Snoring Device is a new surgical tool offering a simple and minimally invasive procedure. Our data demonstrate that the treatment is safe and effective with good patient acceptance. Further patient follow-ups are needed to evaluate the long-term results.

Factors Associated with Successful Treatment by Radiofrequency Treatment of the Soft Palate in Obstructive Sleep Apnea as the First-Line Treatment

Background. Radiofrequency ablation (RFA) is recommended as the second-line treatment for obstructive sleep apnea (OSA). This study aims to study the factors associated with successful treatment by RFA in OSA patients as the first-line treatment. Methods. All patients diagnosed as mild to moderate OSA were enrolled prospectively and treated with RFA. Three points of soft palate were ablated: midline, left, and right paramedian sites. Baseline characteristics and clinical factors including snoring score (SS), Epworth Sleepiness Scale (ESS), and apnea-hypopnea index (AHI), with minimal oxygen saturation, were recorded at baseline and three months after treatment. Results. During the study period, there were 51 patients who met the study criteria and received RFA treatment. At three months, the SS, ESS, and AHI were significantly lower than baseline values, while the minimal oxygenation was significantly increased from the baseline values. There were 16 patients (31.37%) who had an AHI of < 5 times/h. Only baseline AHI was significantly associated with an AHI of < 5 times/h at three months after RFA treatment. The adjusted odds ratio was 0.804 (95% CI: 0.699, 0.924). Conclusion. Transoral RFA treatment may be effective in mild to moderate OSA as the first-line treatment. Baseline AHI is associated with preferable outcome by RFA treatment.

Temperature controlled radiofrequency ablation at different sites for treatment of obstructive sleep apnea syndrome: a systematic review and meta-analysis

BACKGROUND

This study seeks to determine the efficacy of temperature controlled radiofrequency tissue ablation (TCRFTA) to alleviate symptoms of obstructive sleep apnea (OSA) and reduce polysomnographic measures of OSA in the first year post-treatment.

METHODS

Systematic review and meta-analysis. Two independent searches of MEDLINE, EMBASE bibliographic databases, and Evidence Based Medicine Reviews to identify publications relevant to OSA and TCRFTA. Effectiveness of TCRFTA was measured separately for application of TCRFTA at the base of tongue and soft palate, and for multilevel intervention using the respiratory disturbance index (RDI), lowest oxygen saturation (LSAT), Epworth sleepiness scale (ESS), and bed partner's rating of snoring using a visual analogue scale (VAS snoring). The most recent search was conducted in April 2013. Statistical analysis was performed using Review Manager Version 5.2 using a relative measure of effect, i.e., ratio of means (RoM).

RESULTS

Our initial search resulted in 29 eligible studies, and subsequently, 20 studies were included in the meta-analysis. Substantial and consistent improvement in PSG and subjective outcomes were observed post-TCRFTA in the base of tongue (BOT) and multilevel surgery groups only. Application of TCRFTA at the BOT was associated with a significant reduction in RDI (RoM 0.60, CI 0.47-0.76), ESS (RoM 0.59, CI 0.51-0.67), and VAS snoring (RoM 0.48, CI 0.37-0.62) and increase in lowest oxygen saturation (RoM 1.05, CI 1.01-1.10). Similarly, a significant reduction in RDI (RoM 0.61, CI 0.47-0.80) and ESS (RoM 0.79, CI -0.71 to 0.88) was observed after multilevel TCRFTA, but substantial heterogeneity between these studies was observed.

CONCLUSION

TCRFTA is clinically effective in reducing RDI levels and symptoms of sleepiness in patients with OSA syndrome when directed at the base of tongue or as a multilevel procedure.

Recent Developments in the Treatment of Obstructive Sleep Apnea

Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words 'treatment', 'obstructive sleep apnea' and 'sleep-related breathing disorders' and covers papers published since 1997, including references in these articles. In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50-70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary. In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%. Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60-70% have to be regarded as a major challenge warranting further effort.

Snoring management with nasal surgery and upper airway radiofrequency ablation

OBJECTIVE

To review techniques and outcomes of nasal surgery with upper airway radiofrequency ablation (RFA) when used for socially disruptive snoring, including the rate of infection with reused RFA applicator tips.

STUDY DESIGN

Case series with chart review.

SETTING

Community-based sleep-disordered breathing clinic.

METHODS

A prospectively acquired sleep quality assurance database was reviewed to determine demographics, complications, snoring outcomes, level of daytime sleepiness, and sleep-related quality of life in patients with socially disruptive snoring treated with nasal surgery and upper airway RFA.

RESULTS

One hundred thirty patients (48 women; 82 men) with a mean age of 50 years (range, 24-83 years) underwent nasal surgery and upper airway RFA for the treatment of chronic nasal blockage with socially disruptive snoring. All patients underwent septoplasty with or without inferior turbinate reduction and RFA to the soft palate and/or base of tongue. Patients received a mean of 2.2 (range, 1-4) applications of upper airway RFA during the course of treatment. No infections occurred with reuse of applicator tips. Fifty-four bed partners (42%) reported complete snoring resolution, whereas 68 (52%) reported residual snoring that was improved. Snoring resolution was more common in patients who underwent repeated applications of upper airway RFA (odds ratio 2.39; 95% confidence interval, 1.09-5.26).

CONCLUSION

Nasal surgery combined with upper airway RFA improved snoring with few complications in this series of patients with anatomic nasal obstruction with socially disruptive snoring. Reuse of RFA applicator tips at palatal sites reduces cost without an observed increase in the risk of upper airway infection.

Thermal ablation and high-temperature thermal therapy: Overview of technology and clinical implementation

High-temperature hyperthermia or thermal therapy is being applied for destruction of cancerous tissue, eradication or reduction of benign tumours and targeted tissue modification and remodelling. Many of these high-temperature technologies provide a minimally-invasive alternative with lower morbidities compared to the traditional surgical procedures. The effects of high-temperature thermal exposure on tissues, examples of heating technology and procedures of clinical practice related to high-temperature thermal therapy are reviewed. This brief review encompasses interstitial, endocavity, intraluminal and external applications of RF, microwave, ultrasound, laser and thermal conduction energy sources. The technology is prevalent and in various levels of advancement, with the move toward more spatially-accurate and controllable heating systems combined with image-guidance and treatment verification warranted, especially for the treatment of cancer.

[Radiofrequency treatment in simple snoring: tolerance, safety and results]

OBJECTIVE

Snoring is a non-pathologic social problem. In the search for non-aggressive efficacious treatment, we introduce our experience in using temperature-controlled radiofrequency treatment for snoring.

METHODS

A 6-month follow-up revision of thirty-seven patients that received a mean of 1.1 radiofrequency treatment sessions at turbinates, soft palate, tonsils and/or tongue-base.

RESULTS

Mean sample age was 39.6+-9 years; mean BMI was 29.5±4. Good tolerance was presented by 78% of our patients, 78% had no postoperative pain complaints and 68.3% no postoperative symptoms a week after procedure. Minor complications (mainly mucosal breakdown) were presented by 14.6% of the patients. The snoring score went from a mean of 8.6 to 5.6 on the visual analogue scale; 86.5% of the patients improved their clinical snoring and 37.8% were cured of it. Epworth daytime somnolence test results went from mean 9.3 to 6.1.

CONCLUSIONS

Radiofrequency is a procedure that is safe, well-tolerated and fairly painless postoperatively, effective in improving clinical snoring in simple snorers. Radiofrequency is an effective primary treatment for snoring whose cause is accessible to radiofrequency.

Sutter® bipolar radiofrequency volumetric tissue reduction of palate for snoring and mild obstructive sleep apnoea: is one treatment adequate?

Objective:

To evaluate the efficacy of bipolar radiofrequency volumetric tissue reduction, using Sutter® technology, in the treatment of snoring and mild obstructive sleep apnoea.

Design:

Prospective, non-randomised trial.

Methods:

Fifty-two patients with simple snoring and mild obstructive sleep apnoea underwent bipolar radiofrequency palate reduction under local anaesthesia.

Results:

All patients were Friedman stage II and III, with tonsil sizes graded as zero, one or two, a mean body mass index of 22.6, and a mean age of 36.2 years. Seventy-seven per cent of patients reported improvement in their snoring; patients' mean snoring level (assessed by visual analogue scale) improved from 8.9 to 3.4 (p < 0.05). Eighty-three per cent of patients reported an improvement in their Epworth sleepiness scale score, from a mean of 14.6 to 9.5. Seven out of the 17 patients (41.2 per cent) met the surgical success criteria (i.e. at least a 50 per cent reduction of the pre-procedure apnoea–hypopnoea index, and a post-procedure apnoea–hypopnoea index of below 15). Patients' mean apnoea–hypopnoea index improved from 13.6 to 9.8, and their mean lowest oxygen saturation improved from 88.3 to 92.5 per cent. Eighty-two per cent of patients reported an improvement in their quality of life as a result of the procedure.

Conclusion:

One session of Sutter bipolar radiofrequency tissue volume reduction represents a viable method of treating snoring and mild obstructive sleep apnoea, with good results.

Adjustable Tongue Advancement for Obstructive Sleep Apnea: A Pilot Study

Objectives:

Surgical treatment of obstructive sleep apnea (OSA) caused by hypopharyngeal collapse of the upper airway can be considered in patients who are intolerant to continuous positive airway pressure (CPAP). The present procedures addressing the hypopharynx are invasive and have substantial morbidity and limited efficacy.

Methods:

Ten patients (mean age, 44 years) with moderate to severe OSA, ie, an apnea-hypopnea index (AHI) between 15 and 50, with CPAP intolerance were included in a prospective, nonrandomized, multicenter study to evaluate the feasibility, safety, and efficacy of a novel tongue advancement procedure. The procedure consists of the implantation of a tissue anchor in the tongue base and an adjustment spool at the mandible. Titration of this tissue anchor results in advancement of the tongue and a patent upper airway.

Results:

The mean AHI decreased from 22.8 at baseline to 11.8 at the 6-month follow-up (p = 0.007). The Epworth Sleepiness Scale score decreased from 11.4 at baseline to 7.7 at the 6-month follow-up (p = 0.094), and the snoring score decreased from 7.5 at baseline to 3.9 at the 6-month follow-up (p = 0.005). Four technical adverse events were noted, and 1 clinical adverse event occurred.

Conclusions:

Adjustable tongue advancement is a feasible and relatively safe way to reduce the AHI and snoring in selected patients with moderate to severe OSA and CPAP intolerance. Technical improvements and refinements to the procedure are ongoing.

The effect of radiofrequency volumetric tissue reduction of soft palate on voice

The surgical techniques used for snoring and OSA treatment include partial/complete resection or tissue reduction of the oropharyngeal structures such as uvula, tonsilla palatinas, soft palate, lateral pharyngeal tissues and tongue base. So it is predictable for these techniques to affect the resonating volume of the vocal tract and therefore the speech sounds. The goal of this study was to evaluate whether radiofrequency volumetric tissue reduction (RFVTR) of the soft palate can cause voice changes by altering the formant frequencies and fundamental frequency of vowels. A prospective study of 26 habitual snorers and mild obstructive sleep apnea patients (apnea-hypopnea index, <10 in all cases) were investigated before and 6 weeks after RFVTR. The patients received one Somnoplasty RFVTR treatment of 1,400 J per treatment session: 700 J into the midline and 350 J on each side of the soft palate with a maximum temperature of 80 degrees C. Acoustic evaluation was made by the Multidimensional Voice Program. The mean fundamental frequency (MF0) and the first three formant frequencies (F1, F2, F3) of four sustained vowels /a/, /e/, /i/ and /o/ were determined. Comparison between preoperative and postoperative acoustic analysis of the MF0 and F1, F2, F3 of sustained vowels revealed no significant change. The findings of the study indicate that RFVTR of the soft palate as a treatment for snoring and mild forms of OSA does not have a significant impact on the mean fundamental frequency and formant frequencies of vowels. These results seem to be important in management of patients with concerns about postoperative vocal quality, such as singers and professional speakers.

Radiofrequency surgery of the tongue base in the treatment of snoring—a pilot study

In a previously published study, a significant reduction of snoring was reported after treatment with radiofrequency surgery of the tongue base in patients suffering from obstructive sleep apnea syndrome. The aim of this study was to investigate the efficacy of radiofrequency surgery of the tongue base in the treatment of primary snoring. Twenty patients suffering from primary snoring (AHI < 10/h, body mass index < 32 kg/m(2)) and an isolated hypertrophic tongue base at clinical examination were enrolled in this clinical trial. The patients underwent bipolar radiofrequency surgery of the tongue base under local anaesthesia. Pre- and post-operative body weight, daytime sleepiness (Epworth sleepiness scale) and snoring scores (visual analogue scales) were evaluated by the patients and their bed partners, respectively. Postoperative follow-up data was collected 6-8 weeks after treatment. A statistically significant reduction of the preoperative snoring levels from 7.5 +/- 2.4 to 6.1 +/- 2.8 was seen after treatment (p < 0.001). Body weight and daytime sleepiness remained unaffected. Only 3 out of 20 patients were satisfied with the result as defined by VAS < 3. Despite statistically significant reduction of the subjective snoring scores after radiofrequency of the tongue base, only minimal clinical improvement was achieved. Only 3 out of 20 patients were satisfied with the results. With regard to the clearly beneficial effect seen in patients with obstructive sleep apnea, this result indicates different pathophysiological principles in the generation of snoring.

Long-term results of palatal implants for primary snoring

OBJECTIVE

To determine the safety and efficacy of the Pillar Palatal Implant System over a 1-year follow-up period.

STUDY DESIGN AND SETTING

In this prospective study, 40 healthy adult patients with primary snoring due to palatal flutter were treated after clinical, polysomnographic, and endoscopic examination. Under local anesthesia 3 implants were placed into the soft palate. Postoperative morbidity and functional parameters were assessed. Snoring and daytime sleepiness were assessed before and 90, 180, and 360 days after surgery. Objective data were obtained by polysomnography and SNAP-recording before and 90 days after treatment.

RESULTS

All implants were placed without complications. A total of 13 implants partially extruded uneventfully in 10 patients. Functional parameters remained unchanged. After 1 year, snoring was reduced from 7.1 +/- 1.9 to 4.8 +/- 2.5 (Visual-Analogue-Scale, P < 0.05) and daytime sleepiness from 6.1 +/- 3.2 to 4.9 +/- 3.1 (Epworth-Sleepiness-Scale, P < 0.05). SNAP data and polysomnography parameters showed clinically irrelevant changes.

CONCLUSION

Our data demonstrate a significant decrease in snoring and daytime sleepiness over a period of one year.

Radiofrequency tissue volume reduction of the soft palate and UPPP in the treatment of snoring

The purpose of this study was to evaluate the efficiency of radiofrequency tissue volume reduction (RFTVR) and uvulopalatopharyngoplasty (UPPP) in the treatment of snoring in a prospective clinical trial of 79 patients consecutively undergoing surgery for snoring. Seventy-nine patients with primary snoring or mild OSAS (obstructive sleep apnea syndrome) were enrolled in this clinical trial (66 males and 13 females). According to the anatomical findings (the size of the tonsils and uvula), the patients underwent UPPP/TE of the RFTVR of the soft palate. Forty-seven patients had UPPP/TE (age 45.81+/-12.11 years; median AHI: 8; range 1-29). Thirty-two patients were treated with RFTVR of the soft palate (age 48.10+/-10.92; median AHI: 5.0; range 0-26). The average number of treatments was 2.2. All patients underwent preoperative polysomnography to exclude severe OSAS. Pre- and postoperative snoring scores were evaluated from the patients with bed partners. Postoperative follow-up data were collected at a median of 4 months after treatment; 85.1% of the UPPP group and 53.1% of the RFTVR group underwent postoperative polysomnography. Subjective snoring scores of all study participants were evaluated. Preoperatively, there was no statistically significant difference of subjective symptoms, age and BMI between the two groups. The snoring scores improved statistically significantly in both groups (P <0.001 in the UPPP group; P =0.001 in the RFTVR group). After UPPP/TE snoring improved in 37 patients (78.7%), and 29 (61.7%) thereof were free of bothersome snoring; no change was found in 9 patients (19.2%), and 1 (2.1%) worsened. In the RFTVR group, snoring improved in 15 (46.9%), and 9 (28.1%) thereof were free of bothersome snoring; no change was found in 13 patients (50%), and 1 worsened (3.1%). Preoperative AHI was statistically higher (P =0.016) and mean minimal oxygen saturation significantly lower (P =0.002) in the UPPP group. In the UPPP group AHI and HI showed statistically significant improvement postoperatively (P =0.025 and P =0.034, respectively). After RFTVR, no statistically significant change of AHI, HI or oxygen saturation was found. Besides limited mucosal erosions (15%) after RFTVR and foreign body sensations (<10%) after UPPP/TE, no side effects were observed. The success rate of RFTVR of the soft palate is lower compared to the more invasive technique of UPPP. Due to its minimally invasive character, RFTVR is suitable as first-step treatment for snoring, but patients should be counseled about possible success rates and different treatment options.

Incidence of complications in radiofrequency treatment of the upper airway

OBJECTIVES

To investigate the incidence of complications after temperature-controlled radiofrequency (TCRF) treatment of the inferior turbinates, palate, and tongue. To compare these complication rates with those reported in the literature.

STUDY DESIGN

Prospective, observational study.

METHODS

All patients treated with TCRF to the inferior turbinates, palate, and tongues during a 12-month period were included. Data were collected for parameters of energy delivery and the development of complications.

RESULTS

One hundred thirty-six patients were treated with a total of 470 TCRF lesions. The overall incidence of minor complications was 1.2% (6/470 lesions); there were no complications of moderate or major severity.

CONCLUSION

The incidence of minor complications after TCRF in this series was low, and there were no complications of greater severity. These findings are in stark contrast with some previously published papers with higher complication rates. These significantly higher rates may be caused by a marked learning curve, problems in patient selection and the technique of application, excessive energy delivery, and perioperative management.

Alternative surgical dissection techniques

The bipolar scissors, coblator, harmonic scalpel, and somnoplasty techniques are widely available and offer new choices for the operating arena. There are advantages and disadvantages to all four techniques. With time, these dissection methods will prove their lasting power. Otolaryngologists have already begun to expand their applications and will surely play a role in their use and development.

Catheter-based ultrasound applicators for selective thermal ablation: progress towards MRI-guided applications in prostate

High-temperature thermal therapy is emerging as a feasible treatment option for prostate cancer and benign prostatic hyperplasia. Previous investigations have demonstrated distinct advantages of catheter-based ultrasound technology over other heating modalities for thermal ablation therapies, with significant potential for better spatial control and faster heating times. The purpose of this study was to develop ultrasound devices and techniques specifically for treating prostate cancer in conjunction with magnetic resonance thermal imaging (MRTI) to monitor and control treatment progression. Directional transurethral applicators have been designed with arrays of sectored tubular (90 degrees active acoustic sector) or with narrow planar transducer segments and integrated with a flexible delivery catheter with a cooling balloon. This applicator can be rotated within the prostatic urethra to target specific regions during treatment. MRI compatible catheter-cooled interstitial ultrasound applicators with 180 degrees active acoustic sectors were developed specifically to treat the prostate. These applicators may be implanted through the perineum into the posterior portion of the prostate, with their heating energy directed away from the rectum. Both heating strategies were evaluated via biothermal simulations and in vivo experiments within canine prostate (n = 3). During the in vivo studies, MRTI was used to monitor treatment temperatures, cytotoxic thermal doses (t43 > 240 min) and corresponding maximum temperature thresholds (Tmax > 52 degrees C) within three imaging planes simultaneously. Urethral and endorectal cooling was employed with both treatment strategies to provide further protection of the urethral mucosa and rectum from thermal damage. Results using the transurethral applicators demonstrated that narrow zones of coagulation (approximately 30 degrees sector for planar, approximately 90 degrees for tubular), extending up to 20 mm from the urethra to the periphery of the prostate gland, could be produced within 10-15 min. Further, rotation of the applicator during treatment could be used to destroy larger regions in the prostate. Experiments using multiple interstitial directional applicators (approximately 180 degrees active sectors), implanted within the posterior margin of the prostate with the energy directed away from the rectum, produced contiguous zones of thermal coagulation which extended from the posterior prostate toward the anterior-lateral periphery of the gland. Both transurethral and interstitial treatment strategies demonstrated significant potential for thermal ablation of localized prostate cancer, particularly when MRTI is used to guide and assess treatment.

Telescopic-Assisted Radiofrequency Adenoidectomy: A Prospective Randomized Controlled Trial

OBJECTIVES/HYPOTHESIS

The objective was to conduct a prospective randomized controlled trial describing and investigating the efficacy and safety of transoral telescopic-assisted radiofrequency adenoidectomy in young children.

STUDY DESIGN

Prospective randomized controlled trial.

METHODS

One hundred twenty patients who were 36 months of age or less and planned to undergo adenoidectomy or adenoidectomy with insertion of tympanostomy tubes were included in the study. Children were prospectively and randomly assigned into two equal treatment groups: the telescopic-assisted adenoidectomy using radiofrequency curette and the conventional adenoid-curette adenoidectomy. The main parameters included visual analogue scale score for nasal breathing, amount of blood loss, operating time, completeness of adenoid resection, smoothness of postoperative recovery, and complications.

RESULTS

Both groups had a significant improvement in the visual analogue scale score after surgery with no evidence for a significant difference between the conventional adenoid-curette and radiofrequency groups. The amount of blood lost during radiofrequency adenoidectomy was minimal, with a mean difference of 31 mL and a median difference of 26 mL. There was a tendency for shorter operative time in the radiofrequency group, but this did not reach a statistical significance. No evidence for a significant difference was noticed in the smoothness of postoperative recovery or complication rate.

CONCLUSION

Telescopic-assisted radiofrequency-curette adenoidectomy allows removal of huge adenoids completely in a precise, easy, and cost-effective procedure, with minimal blood loss and short operating time. The use of transoral telescopes provides a clear visualization that helps complete removal of the adenoids, reduction of unnecessary trauma, and effective control of bleeding.

Combined radiofrequency surgery of the tongue base and soft palate in obstructive sleep apnoea

OBJECTIVE

To investigate the safety and efficacy of combined temperature-controlled radiofrequency volumetric tissue reduction of the tongue base and soft palate in obstructive sleep apnoea.

MATERIAL AND METHODS

A total of 20 patients with obstructive sleep apnoea and combined palatal and retrolingual obstruction were included in a non-randomized clinical trial and 51 combined treatments were performed under local anaesthesia. Postoperative pain was assessed using visual analogue scales. Functional parameters, daytime sleepiness and quality of life were assessed using questionnaires (Epworth Sleepiness Scale, Short Form-36) before and 12 weeks after the last treatment session. Concurrently, polysomnography was performed on two consecutive nights. Results The mean postoperative pain score dropped from 5.6 at Day 1 to 0.6 at Day 7. Painkillers were taken for a mean of 3.3 days. There were no postoperative complications or changes in functional parameters. Daytime sleepiness improved significantly (p<0.05). The mean respiratory disturbance index was reduced from 25.3+/-11.4 to 16.7+/-15.3 (p<0.05). Six out of 18 (33%) patients were cured after a mean of 2.7 treatment sessions.

CONCLUSION

Combined radiofrequency volumetric tissue reduction of the tongue base and soft palate is a safe and effective treatment for obstructive sleep apnoea.

Pilot study of a novel mandibular advancement device for the control of snoring

OBJECTIVE

Mandibular advancement devices (MADs) have been introduced as a conservative, non-invasive treatment for socially disturbing snoring and mild obstructive sleep apnea (OSA). A prospective, non-randomized pilot study was conducted to investigate the efficacy, feasibility, side-effects and compliance of Somnoguard, an immediately intraorally adaptable MAD made from thermoplastic material.

MATERIAL AND METHODS

Twenty consecutive heavy snorers with a respiratory disturbance index of <20 events/h were prospectively selected. Prior to the adaptation of the appliance, ambulatory polygraphy was carried out without a MAD. After a 1-month habituation period, a polygraphic evaluation was carried out with the device. Treatment success was defined as a reduction in the apnea-hypopnea index (AHI) of at least 50%.

RESULTS

The results indicated a success rate of 65%. The AHI decreased from 8.4 +/- 2.9 events/h at baseline to 3.9 +/- 1.8 events/h with the device (p = 0.001). At 1-month follow-up, significant reductions in the snoring index (p < 0.001) and the Epworth Sleepiness Scale (ESS) score (p = 0.036) were noted. At 6-month follow-up, similar results were achieved, with significant drops in the snoring index (p = 0.025) and ESS score (p = 0.033).

CONCLUSION

We conclude that immediate intraoral adaptation of a low-cost fabricated "one-size-only" MAD is a feasible and well-tolerated treatment for snoring and mild OSA. Further research is needed to evaluate this thermoplastic appliance as a strategy to "screen" the efficacy of MAD treatment in the individual patient with a less expensive appliance before constructing a more expensive custom-made MAD.

Percutaneous MR Imaging– guided Radiofrequency Interstitial Thermal Ablation of Tongue Base in Porcine Models: Implications for Obstructive Sleep Apnea Syndrome

PURPOSE

To test the feasibility and safety of a percutaneous magnetic resonance (MR) imaging-guided technique for radiofrequency (RF) interstitial thermal ablation of the tongue base and to correlate MR appearance of induced thermal lesions with histopathologic findings in pigs in acute and chronic porcine models.

MATERIALS AND METHODS

A 1-cm-tip RF electrode was inserted percutaneously into the tongue in 10 pigs with 0.2-T real-time MR guidance. The RF electrode was advanced up the midline between lingual arteries and stopped short of tongue mucosa. RF interstitial thermal ablation was performed at 90 degrees C +/- 2 and lasted 10 minutes. Postablation images were obtained with a 1.5-T MR imager. Five pigs were sacrificed immediately (acute model), while five were followed up for 1 month (chronic model) before they were sacrificed. MR-compatible fiducial coils were inserted into tongues with MR imaging guidance prior to RF ablation in the chronic group. Tongues were harvested for histopathologic analysis. Mean thermal lesion volume was compared with the Student t test on images obtained immediately, 2 weeks, and 1 month after RF ablation. Interclass correlation coefficients of lesion diameters at gross pathologic analysis and corresponding diameters with each pulse sequence were calculated.

RESULTS

Successful MR imaging-guided electrode positioning was achieved in all procedures without intra- or postprocedure complications because there was high vascular conspicuity and tissue contrast. Thermal lesions appeared hypointense with hyperintense surrounding rims with all sequences in both groups. At pathologic analysis, acute lesions appeared as pale necrotic areas surrounded by hyperemic rims, while chronic lesions demonstrated progressive circumferential fibrosis and significant volume shrinkage (P <.01). Thermal lesion diameters measured at gross pathologic analysis best agreed with corresponding diameters measured on short inversion time inversion-recovery images (interclass correlation coefficient = 0.85).

CONCLUSION

The results of this investigation demonstrate MR imaging-guided RF interstitial thermal ablation of the tongue base is feasible and safe and illustrate imaging and pathologic phenomena associated with creation and evolution of the induced thermal lesions.

Postoperative Pain and Side Effects After Uvulopalatopharyngoplasty, Laser-Assisted Uvulopalatoplasty, and Radiofrequency Tissue Volume Reduction in Primary Snoring

OBJECTIVES

We compared, in a prospective study, the side effects and the postoperative complications of three procedures commonly used for the treatment of primary snoring.

METHOD

Forty-nine patients underwent velopharyngeal surgery for primary snoring (17 for uvulopalatopharyngoplasty [UPPP]; 15 for laser-assisted uvulopalatoplasty [LAUP], and 17 for radiofrequency tissue volume reduction [RFTVR]). Preoperative full polysomnographic studies ruled out obstructive sleep apnea syndrome. Each patient's evaluation encompassed postoperative pharyngeal pain (as measured by a 5-point visual analogue scale) and use of narcotic drugs in the early postoperative period as well as a subjective evaluation of late postoperative complaints. A surgeon's examination was performed to report postoperative complications in the oropharynx.

RESULTS

Postoperative pharyngeal pain was less important in the RFTVR group than in the UPPP and LAUP groups. Mean scores at days 3, 7, 16 were as follows: 4.2, 4.0, and 2.4, respectively, for UPPP; 4.6, 3.8, and 1.6 for LAUP; and 2.4, 2.0, and 0.7 for RFTVR. Mean duration of pain with a score greater than 2 was calculated as follows: UPPP, 21.3 days; LAUP, 15.1 days; and RFTVR, 6.1 days. Mean duration of narcotic drug use for the patients who needed this medication was 10.1 days for UPPP, 7.2 days for LAUP, and 1.3 for RFTVR. Postoperative side effects (trouble with smell and taste, pharyngeal dryness, globus sensation, voice change, and pharyngonasal reflux) were more present in the UPPP and LAUP groups than in the RFTVR group. Surgeon's assessment for postoperative complications reported more wound infection, dehiscence, and posterior pillar narrowing in the UPPP and LAUP groups than in the RFTVR group.

CONCLUSION

RFTVR is a safer and less painful procedure than UPPP and LAUP for the treatment of primary snoring. Postoperative discomfort after LAUP and after UPPP appears to be very similar.

[Magnetic resonance imaging in the evaluation of temperature-controlled radiofrequency volumetric tissue reduction]

BACKGROUND

Due to its minimally invasive character, radiofrequency surgery has become a topic of increasing attention, especially with respect to the surgical treatment of sleep-related breathing disorders. Temperature-controlled radiofrequency volumetric tissue reduction is the most common technique employed in these cases. However, despite the increasingly widespread use of this technique, there is little data available on the induced effects in vivo. The aim of the present study was to investigate whether magnetic resonance imaging could be used in the evaluation of the in vivo effects of radiofrequency surgery at the base of the tongue.

PATIENTS AND METHODS

Six patients were treated at the base of tongue with radiofrequency surgery. At 4-6, 8-10 and 24 h after surgery, magnetic resonance imaging was performed using an inversion recovery technique (TIRM) and the lesions created were evaluated.

RESULTS

The lesions could be visualised at all postoperative measurement times. They appeared as oval hypointense structures encircled by a hyperintense area. Lesion size diminished slightly over time.

DISCUSSION

Lesions induced by radiofrequency surgery can be clearly visualised with magnetic resonance imaging. Lesion size may be assessed in relation to energy application. In the future, the treatment of sleep-related breathing disorders may be further optimised with the help of this technique.

Somnoplastia: tratamiento del ronquido crónico mediante radiofrecuencia sobre el paladar

The goal of this study is to evaluate the efficacy and the safety of tissue reduction of the palate by means of radiofrequency for the treatment of snoring. Fifty-three patients were evaluated. Eight of them (15%) met criteria for mild OSAS. All of them underwent RF energy treatment with several ablation sites and the mean total energy administered was about 2500 J per treatment session. 40 patients (75%) underwent an additional RF treatment and the energy administered in the second session was the same as in the first one. We evaluated postoperative pain, snoring and the satisfaction of the patient and his enviroment. After a mean follow-up of 20 months no adverse effect was reported. The success diminishes with time as happens other surgical procedures (UPPP or LAUP) but the absence of serious adverse side-effects and the minimal postoperative pain support the use of RF as an effective procedure for reducing snoring.

Voice quality after radiofrequency volumetric tissue reduction of the soft palate in habitual snorers

OBJECTIVE

To evaluate whether radiofrequency volumetric tissue reduction of the soft palate is causing voice changes as a result of velopharyngeal insufficiency in patients with heavy snoring.

STUDY DESIGN

A prospective study of 16 habitual snorers (oxygen desaturation index, <6 in all cases) were investigated concerning nasopharyngeal competence before and, at minimum, 2 months after the procedure (mean period, 165 d). Speech evaluation was made objectively with a nasal-oral ratio meter and also was made subjectively by a trained speech-language pathologist. The patients received a mean of three Somnoplasty radiofrequency volumetric tissue reduction treatments of 1200 J each (600 J in the midline and 300 J on each side of the soft palate).

RESULT

Comparison between preoperative and postoperative nasal-oral ratio meter analysis of hypernasality revealed no significant change. Neither did listener judgment of hypernasality, nasal escape, or pharyngeal snort reveal any influence on velopharyngeal function by the surgical procedures. Snoring was somewhat successfully treated, as evaluated by spouses; snoring score was reduced from 8.2 +/- 2.9 to 4.1 +/- 2.5 (P <.01) on a 10-grade rating scale. Maximum nocturnal decibel levels were also reduced in 79% of the cases.

CONCLUSION

Radiofrequency volumetric tissue reduction in the soft palate as a treatment for snoring did not show any significant adverse effect on nasopharyngeal function.