Palatal implants: a new method for the treatment of snoring

Potential of computational models in personalized treatment of obstructive sleep apnea: a patient-specific partial 3D finite element study

The upper airway experiences mechanical loads during breathing. Obstructive sleep apnea is a very common sleep disorder, in which the normal function of the airway is compromised, enabling its collapse. Its treatment remains unsatisfactory with variable efficacy in the case of many surgeries. Finite element models of the upper airway to simulate the effects of various anatomic and physiologic manipulations on its mechanics could be helpful in predicting surgical success. Partial 3D finite element models based on patient-specific CT-scans were undertaken in a pilot study of 5 OSA patients. Upper airway soft tissues including the soft palate, hard palate, tongue, and pharyngeal wall were segmented around the midsagittal plane up to a width of 2.5 cm in the lateral direction. Simulations of surgical interventions such as Uvulopalatopharyngoplasty (UPPP), maxillo-mandibular advancement (MMA), palatal implants, and tongue implants have been performed. Our results showed that maxillo-mandibular advancement (MMA) surgery of 1 cm improved the critical closing pressure by at least 212.2%. Following MMA, the best improvement was seen via uvulopalatopharyngoplasty (UPPP), with an improvement of at least 19.12%. Palatal and tongue implants also offered a certain degree of improvement. Further, we observed possible interacting mechanisms that suggested simultaneous implementation of UPPP and tongue stiffening; and palatal and tongue stiffening could be beneficial. Our results suggest that computational modeling is a useful tool for analyzing the influence of anatomic and physiological manipulations on upper airway mechanics. The goal of personalized treatment in the case of OSA could be achieved with the use of computational modeling.

Complications of Palatal Pillar Implants: An analysis of the MAUDE database and literature review

PURPOSE

The Pillar Palatal Implant System is a minimally invasive procedure for the treatment of obstructive sleep apnea and snoring. Prior studies have examined the effectiveness of this procedure, however no prior study has thoroughly evaluated its complications. We anticipate that this analysis will provide valuable insight into these procedures which can be used in patient education and post-operative follow-up.

MATERIALS AND METHODS

The Manufacturer and User Facility Device Experience (MAUDE) database was queried for cases reporting injury related to the pillar procedure. The case narratives were individually analyzed and categorized by type of complication. A comparison of extruding parts and select complications was also performed using chi-square analysis.

RESULTS

Of the 261 cases reported, 73.6% reporting extruding parts, 47.5% described patient pain, and 38.7% included patients describing a foreign body sensation. Infection was reported in 7.7% of the cases with cellulitis and abscess formation specifically mentioned in one case. Cases describing pain and difficulty swallowing were significantly more likely to have reported extruding parts (p < 0.05).

CONCLUSIONS

This study describes various complications associated with this procedure. The description of these complications and accompanying literature review may provide healthcare professionals and patients with an understanding of the scope of adverse events related to this procedure.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

OBJECTIVE

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review.

DATA SOURCES

PubMed, CINAHL, and Web of Science searches from inception to 2018.

REVIEW METHODS

English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers.

RESULTS

Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control.

CONCLUSION

Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

Biomechanics of the soft-palate in sleep apnea patients with polycystic ovarian syndrome

Highly compliant tissue supporting the pharynx and low muscle tone enhance the possibility of upper airway occlusion in children with obstructive sleep apnea (OSA). The present study describes subject-specific computational modeling of flow-induced velopharyngeal narrowing in a female child with polycystic ovarian syndrome (PCOS) with OSA and a non-OSA control. Anatomically accurate three-dimensional geometries of the upper airway and soft-palate were reconstructed for both subjects using magnetic resonance (MR) images. A fluid-structure interaction (FSI) shape registration analysis was performed using subject-specific values of flow rate to iteratively compute the biomechanical properties of the soft-palate. The optimized shear modulus for the control was 38 percent higher than the corresponding value for the OSA patient. The proposed computational FSI model was then employed for planning surgical treatment for the apneic subject. A virtual surgery comprising of a combined adenoidectomy, palatoplasty and genioglossus advancement was performed to estimate the resulting post-operative patterns of airflow and tissue displacement. Maximum flow velocity and velopharyngeal resistance decreased by 80 percent and 66 percent respectively following surgery. Post-operative flow-induced forces on the anterior and posterior faces of the soft-palate were equilibrated and the resulting magnitude of tissue displacement was 63 percent lower compared to the pre-operative case. Results from this pilot study indicate that FSI computational modeling can be employed to characterize the mechanical properties of pharyngeal tissue and evaluate the effectiveness of various upper airway surgeries prior to their application.

Palatal implant surgery effectiveness in treatment of obstructive sleep apnea: A numerical method with 3D patient-specific geometries

Obstructive sleep apnea (OSA) affects a large percentage of the population and is increasingly recognized as a major global health problem. One surgical procedure for OSA is to implant polyethylene (PET) material into the soft palate, but its efficacy remains to be discussed. In this study, we provide input to this topic based on numerical simulations. Three 3 dimensional (3D) soft palate finite element models including mouth-close and mouth-open cases were created based on three patient-specific computed tomography (CT) images. A simplified material modeling approach with the Neo-Hookean material model was applied, and nonlinear geometry was accounted for. Young's modulus for the implant material was obtained from uniaxial tests, and the PET implant pillars were inserted to the 3D soft palate model. With the finite element model, we designed different surgical schemes and investigated their efficacy with respect to avoiding the soft palate collapse. Several pillar schemes were tested, including different placement directions, different placement positions, different settings for the radius and the array parameters of the implant pillars, and different Young's moduli for the pillars. Based on our simulation results, the longitudinal-direction implant surgery improved the stiffness of the soft palate to a small degree, and implanting in the transverse direction was evaluated to be a good choice for improving the existing surgical scheme. In addition, the Young's modulus of the polyethylene material implants has an influence on the reinforcement efficacy of the soft palate.

Soft Palate Implants for the Treatment of Mild to Moderate Obstructive Sleep Apnea

OBJECTIVE: To evaluate the initial short-term effectiveness of palatal implants in treating patients with mild to moderate obstructive sleep apnea (OSA). Previous published studies have focused on snoring without OSA.

STUDY DESIGN: A prospective, nonrandomized study of 25 previously untreated patients with an apnea-hypopnea index (AHI) of 10 to 30 and a body mass index (BMI) of ≤30. Three permanent implants (Pillar; Restore Medical, St Paul, MN) were placed in the soft palate of each patient with a specially designed delivery tool in an office setting under local anesthesia after a formal polysomnography. A repeat polysomnography was obtained after 90 days.

RESULTS: The AHI was reduced from a mean of 16.2 to a mean of 12.1 (P < 0.05) for the study group. Twenty of 25 patients (80%) experienced a decrease in the AHI. Twelve of 25 patients (48%) showed a post-90-day implant AHI of 10 or less, a benchmark for the possible cessation of continuous positive airway pressure therapy. The Epworth Sleepiness Score decreased from 9.7 to 5.5 ( P < 0.001) and the visual analog Scale of snoring intensity reported by bed partners decreased from 8.4 to 4.3 ( P < 0.001).

CONCLUSION: The palatal implant method can significantly improve AHI and other sleep-related parameters in patients with mild to moderate OSA and a BMI of ≤30. Short-term results are comparative to those reported for uvulopalatopharyngoplasty but achieved in a low-cost, single-stage, outpatient office setting with low morbidity.

Consequences of Increased Rigidity in Palatal Implants for Snoring: A Randomized Controlled Study

OBJECTIVES: Palatal implants have seen an increased role in the treatment of snoring. In this study, we evaluate the safety and possible treatment effect of adding further stiffness to the palate through the use of a more rigid implant.

STUDY DESIGN: Randomized double-blind study of 20 patients with primary snoring. Three polyethylene teralphate implants were placed in the soft palate with the patient under local anesthesia. Ten patients received regular implants (rigidity 1.0) and 10 patients received stiffer implants (rigidity 1.8). The patients and their bed partners were followed for 6 months with questionnaires and office visits. A sleep study was performed preoperatively and at the last follow-up.

RESULTS: Four of the 10 patients with stiffer implants had 5 partial extrusions in the observation period. There was a nonsignificant reduction in snoring intensity from 8.1 to 6.1 evaluated by the bed partner on a visual analogue scale in this group. No extrusions were seen in the group with regular implants. This group showed a significant reduction in snoring intensity from 7.7 to 4.7. No other major adverse events were observed.

CONCLUSIONS AND SIGNIFICANCE: Rigid implants cause short time extrusions with loss of treatment effect. Regular implants reduce palatal snoring intensity with high patient and bed partner satisfaction.

EBM rating: A-1b

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.

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

OBJECTIVE: To evaluate the safety and long-term effectiveness of a new treatment for snoring using permanent palatal implants.

STUDY DESIGN: Prospective study with 35 patients referred to the clinic for the treatment of snoring. The patients were followed for 1 year, and a sleep analysis was performed and repeated at 360 days. During the procedure, 3 braided polyethylene terephthalate implants were placed in the palate of each patient.

RESULTS: The average duration for nonnarcotic analgesics was 1.3 days. No adverse events were observed. The mean snoring intensity was reduced from 7.1 at baseline to 4.8 at 1 year ( P < 0.001). Bed partner satisfaction rate was very high at 70.6% after 1 year. Six patients (17.8%) experienced a total of 9 partial extrusions.

CONCLUSIONS: The palatal implant system is safe, and the effectiveness in treating snoring is comparable to other surgical methods. Advantages are virtually no tissue damage and minimal patient discomfort as a result of one standardized, low-cost procedure.

TranQuill sling snoreplasty for snoring: A single-arm pilot study for safety and effectiveness

OBJECTIVES/HYPOTHESIS

Determine safety and efficacy of the TranQuill Sling Snoreplasty (TSS) (Surgical Specialties Corp., Vancouver, BC, Canada) for the treatment of snoring in adults with benign snoring or mild obstructive sleep apnea.

STUDY DESIGN

Prospective, unblinded, single-center pilot study.

METHODS

From February 2014 to July 2014, 20 adult patients with chronic, disruptive snoring assessed by bed partner were recruited to undergo TSS. Subjects with apnea hypopnea index < 15, minimum oxygen saturation > 85%, and body mass index (BMI) < 32 were included. Outcomes were assessed comparing the results of quality-of-life questionnaires, bed partner-assessed snoring, pain visual analog scales, WatchPAT (Itamar Medical Ltd, Caesarea Ind. Park, Israel) home sleep studies, and flexible endoscopy at baseline and 90-day follow-up.

RESULTS

Thirteen males and seven females were enrolled. Average age was 49.1 (range 31-67) and BMI of 25.8 ± 2.66. TranQuill Sling Snoreplasty significantly reduced snoring symptom scores from 8.70 ± 4.27 to 6.42 ± 4.14, P = 0.012. Snoring visual analog scores demonstrated reduction of 17.8 mm (59.4 mm ± 22.1 to 41.6 mm ± 29.2), P = 0.0184. Thirty-five percent (7/20) of subjects reported complications related to the trial, with no serious adverse events.

CONCLUSION

TranQuill Sling Snoreplasty is a safe therapy that improves snoring symptoms in most adult subjects with benign snoring or mild sleep apnea. Further study is required to better identify patients likely to respond to the therapy.

Four-year outcomes of palatal implants for primary snoring treatment: a prospective longitudinal study

OBJECTIVES/HYPOTHESIS

The objective of this study was to evaluate the long-term effectiveness of palatal implants as the treatment of primary snoring.

STUDY DESIGN

Prospective longitudinal cohort study.

METHODS

This study compared snoring outcomes before and after soft palate implantation for patients diagnosed with primary snoring (no sleep apnea). Snoring severity was obtained by the subjects' sleep partners on a 10-point Likert scale. A paired Student t test compared the mean scale values preoperatively at week 52 and at the current 4-year follow-up. Body mass index for each patient was also compared to evaluate for any significant confounders.

RESULTS

Data were obtained from 23 patients out of 26 who were followed for the full study term. The follow-up time was on average 4 years following palatal implantation. A statistically (P < .016) and clinically significant improvement in the snoring scale was noted when comparing snoring severity between the preoperative and 4-year period and between the 52-week and 4-year scores. Although statistically significant improvement was found between the preoperative period and 52 weeks, there was a clinical deterioration in snoring scale scores between 52 weeks and 4 years. The mean (standard deviation) preoperative score was 9.5 (0.5), mean week-52 score was 5.0 (1.6), and mean 4-year score was 7.0 (1.8). Body mass index did not change through the observation interval.

CONCLUSIONS

Soft palate implantation is a possible surgical technique with which to attempt to achieve subjective improvement of primary snoring severity. Subjective improvement, however, deteriorates significantly over time, and is only minimally sustained at 4 years postoperatively. This study provides new information on long-term palatal implant effectiveness.

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).

Effect of palatal implants on continuous positive airway pressure and compliance

OBJECTIVE

Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy.

STUDY DESIGN

Randomized, double-blind, placebo-controlled study.

SETTING

Four geographically dispersed tertiary sleep disorder referral centers.

METHODS

Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report.

RESULTS

Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04).

CONCLUSION

Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.

Effects of soft palate implants on acoustic characteristics of voice and articulation

OBJECTIVE

To evaluate the effects of soft palate implants on voice and articulation.

STUDY DESIGN

Prospective case series.

METHODS

Male subjects (n=23) diagnosed with mild obstructive sleep apnea and/or habitual snoring underwent acoustic analysis with the Multidimensional Voice Program (Kay Multi-Speech Model 3700 Advanced Version; Kay Elemetrics [KayPentax], Lincoln Park, NJ) before and 8 weeks after insertion of palatal implants to determine the effects of soft palate implants on voice and articulation. Sustained vowels (/a/e/u/o/i/) and phonetically balanced carrier sentences were used for acoustic analyses. Parameters measured were fundamental frequency (F0), jitter, shimmer, noise-to-harmonics ratio, Voice Turbulence Index, Soft Phonation Index, degree of voiceless, degree of voice breaks and peak amplitude variation, first formant (F1) and second formant (F2) frequencies, and voice onset time (VOT). F1 and F2 for each vowel were determined using linear predictive analysis on a spectrogram. VOT was measured for the palatal consonant /k/ and the dental consonant /t/ on a wideband spectrogram from a carrier sentence segment that contained a syllable with a stop consonant.

RESULTS

No statistically significant difference was detected in F0, F1, F2, or other MDVP parameters before and after implantation. Average VOT values measured for /t/ were not significantly different. On the other hand, average VOT values of /k/ were found to be significantly shorter.

CONCLUSIONS

Implant insertion had no significant effect on MDVP parameters, F0, F1, or F2. On the other hand, articulation as a function of velar region seemed to be affected because VOT values of velar /k/ were changed.

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.

Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea

CONCLUSION

The palatal implant method originally designed to reduce snoring can significantly reduce the apnea-hypopnea index (AHI) in some patients with mild to moderate obstructive sleep apnea (OSA) in a single office-based procedure.

OBJECTIVE

An initial study designed to evaluate the short-term efficacy and safety of palatal implants as primary treatment for patients with mild to moderate OSA.

MATERIALS AND METHODS

This was a prospective, non-randomized study of 16 previously untreated and undiagnosed patients with sleep apnea. The inclusion criteria were an AHI of 10-30/h and a body mass index (BMI) < or = 30.

RESULTS

The mean AHI was reduced following implantation, from 16.1 to 11.8 (p<0.01). A reduction in AHI was achieved in 13 patients (81%). Ten of 16 patients had their AHI reduced to <10.0. Snoring intensity decreased from 8.3+/-1.8 to 4.7+/-2.5 on a visual analog scale (p<0.001) and daytime sleepiness dropped from 7.2+/-2.5 to 4.6+/-3.2 on the Epworth Sleepiness Scale (p<0.05). No significant adverse events were reported.

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.

Palatal implants: a new approach for the treatment of obstructive sleep apnea

OBJECTIVE

To evaluate the short-term safety and efficacy of palatal implants in patients with mild and moderate obstructive sleep apnea (OSA).

STUDY DESIGN AND SETTING

A prospective, non-randomized study conducted at 5 clinical sites. Three polyester implants were placed in the soft palate under local anesthesia during a single-stage office procedure. Polysomnography was conducted at baseline and 90 days post-procedure. Subjective quality of life data were collected.

RESULTS

Fifty-three patients were evaluated; the apnea hypopnea index (AHI) decreased from 25.0 +/- 13.9 to 22.0 +/- 14.8 events/hour (P = 0.05). The Epworth Sleepiness Scale (ESS) decreased from 11.0 +/- 5.1 to 6.9 +/- 4.5 (P < 0.001), and the snore score decreased from 7.9 +/- 2.1 to 4.0 +/- 3.0 (P < 0.001). No serious complications occurred during the study.

CONCLUSION

Palatal implants can be an effective initial low morbidity treatment option for patients diagnosed with mild to moderate OSA.

Initial U.S. pilot study: palatal implants for the treatment of snoring

OBJECTIVE

To assess efficacy of polyethylene terephthalate (PET) implants in the soft palate for the treatment of socially significant snoring.

DESIGN

A prospective, interventional case series.

SETTING

Hospital-based multi-specialty clinic.

PATIENTS

Twenty-five consecutive patients with socially significant snoring without history of obstructive sleep apnea.

INTERVENTION

Three PET implants were inserted into the soft palate of each patient (Pillar procedure, Restore Medical, Inc., St. Paul, Minnesota).

MAIN OUTCOME MEASURE

Change in snoring severity measured by the bed partner using a 10-centimeter visual analog scale (VAS) where 0 = "no snoring noise" and 10 = "extreme snoring noise causing (the bed partner) to leave the bedroom."

RESULTS

Ninety-day follow-up data was collected for 21 patients. Four patients had incomplete follow-up. Snoring VAS rated by the bed partner had a baseline mean value of 8.5 +/- 1.4, which decreased to 5.0 +/- 2.1 at 30 days and to 4.4 +/- 2.5 at 90 days (P < 0.001). All patients tolerated the procedure well and no procedure-related complications were observed. Two implants partially extruded in 1 patient within the 90-day follow-up period, for an implant partial extrusion rate of 2.7% (2/75 implants) and patient partial extrusion rate of 4% (1/25 patients). At 90 days, 75% of patients and 90% of their bed partners recommended the procedure.

CONCLUSIONS

In this case series, PET implants into the soft palate significantly reduced snoring with few extrusions and no complications. Controlled studies are needed to confirm effectiveness and to refine patient selection criteria.

EBM RATING

C-4.

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.