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

Patient Selection and Efficacy of Pillar Implant Technique for Treatment of Snoring and Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE: Pillar implant (PIT) is a simple, office-based procedure with minimal morbidity that was introduced in 2003 to treat snoring and mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). We studied the: (1) success rate using subjective symptoms and objective polysomnographic improvement; (2) success rate based on BMI, OSAHS severity and Friedman tongue position (FTP); and (3) its value as an adjunctive or revision procedure.

STUDY DESIGN AND SETTING: Retrospective review of 125 patients who underwent the PIT for snoring and OSAHS. Patients were grouped: Group I had PIT only ( n = 29); Group II received adjunctive nasal procedures ( n = 37), Group III received adjunctive oropharyngeal procedures ( n = 55); and Group IV had failed previous UPPP ( n = 4).

RESULTS: Overall subjective and objective “cure” rates were 88.0% and 34.4%, respectively. Group IIb had the best objective cure rate of 46.7%. Neither AHI nor BMI correlated with outcome measures, whereas FTP did correlate. (FTP I and II had improved success vs FTP III and IV). Ten patients had partial extrusion of the PIT. These were removed and new PIT were carried out at a later date.

CONCLUSIONS: Based on a short-term study, the Pillar implant is an effective treatment for snoring and OSAHS in selected patients and can be combined with adjunctive procedures to treat OSAHS.

Treatment of obstructive sleep apnea syndrome using radiofrequency-assisted uvulopalatoplasty with tonsillectomy

Radiofrequency surgery was introduced to minimize thermal damage to the tissue. A radiofrequency electrode can be used to make cuts in the free edge of the soft palate like those done in laser-assisted uvulopalatoplasty [radiofrequency-assisted uvulopalatoplasty (RAUP)]. Tonsillectomy can enlarge the lateral diameter of the pharynx. The aim of our study was to evaluate the efficacy of RAUP with tonsillectomy in treatment of obstructive sleep apnea syndrome (OSAS). Ninety-two patients with obstructive sleep apnea were included in this study. Patients were categorized according to disease severity and Friedman's staging system. Patients were assessed with the preoperative visual analog scale (VAS) for snoring, Epworth Sleepiness Scale (ESS) and apnea-hypopnea index (AHI) at baseline and repeated at 6 months postoperatively. The intensity of postoperative pain, speech deficits and dysphagia were also recorded. There was a significant improvement in the VAS score for snoring, ESS and AHI before and after surgery. Overall, the results of the present study indicated a surgery success rate (a 50 % decrease in AHI and AHI <20) of 66 % (61 of 92 patients). Postoperative pain, speech deficits and dysphagia were reduced at 2 weeks after surgery. The results of this study suggest that RAUP with tonsillectomy is an effective treatment for patients with OSAS.

The surgical treatment of sleep-related upper airway obstruction

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis

A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.

[Guideline: Treatment of obstructive sleep apnea in adults]

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

Randomized-controlled study comparing post-operative pain between coblation palatoplasty and laser palatoplasty

OBJECTIVES

This study aimed to evaluate differences in post-operative pain comparing KTP laser-assisted uvulopalatoplasty without tonsillectomy (LAUP) with a new described surgical method: coblation uvulopalatoplasty with tonsillectomy (CP). We also evaluate the impact of each surgical technique in reduction of snoring loudness.

MATERIAL AND METHODS

Single blind randomized-controlled trial. From a population of 41 consecutive patients on the waiting list for uvulopalatoplasty for simple snoring, the study group was reduced to 17 CP and 13 LAUP. Post-operative pain and reduction of snoring loudness were recorded using visual analogue scales (VAS) during the first 15 post-operative days. Post-operative snoring loudness was documented for 1-year period.

RESULTS

Both groups had similar post-operative pain during the first seven post-operative days. A statistically significant reduction in post-operative pain was observed in the CP group after day 8, and maintained until the end of the study. Reduction of snoring loudness was significant in both groups, but no differences were observed between them.

DISCUSSION

Coblation uvulopalatoplasty compared with LAUP demonstrates a reduction in post-operative pain, significant after the first post-operative week. The collateral thermal injury caused by laser is responsible for the slow-healing rate and maintained post-operative pain. Coblation dissociates tissue at lower temperatures with minimal collateral thermal injury and consequently faster and less painful recovery. Both surgical procedures have significant and similar reduction in snoring loudness.

CONCLUSIONS

Both methods are adequate treatment options for snoring. The less painful recovery in CP promotes this surgical technique as our preferred choice for palate surgery.

[Anaesthetic management of adult patients with obstructive sleep apnea syndrome]

OBJECTIVE

The purpose of this review article is to update the anaesthetic management of adult patients with obstructive sleep apnoea syndrome (OSAS).

DATA SOURCES

All references obtained from the medical database Medline related to OSAS and anaesthesia from 1963 until May 2006 were reviewed. References included original articles, observations, clinical cases, and reviews published in English or in French.

DATA SYNTHESIS

The anaesthetic literature related to OSAS and anaesthesia is poor. Understanding anatomy and pathophysiology is important for an optimal anaesthetic management. Since the diagnosis is unknown in almost 80-90% of these patients, many undergo general or regional anaesthesia every day without recognition of the main dangers associated with the condition. Recognition of these patients, especially in the preanaesthetic assessment, is an essential step to prevent perioperative complications. Patients with OSAS are very sensitive to sedatives, hypnotics and opioids. The use of these drugs must be controlled and monitored. Anticipation of difficult intubation avoids complications during induction of general anaesthesia and the use of nasal CPAP decreases the incidence of respiratory complications in the perioperative period.

CONCLUSION

Further research is needed in this field of anesthesia. Intraoperative difficulties in the control of airway and postoperative cardiac and respiratory complications may happen. The use of nasal CPAP in the perioperative period makes the anaesthetic management easier and safer.

Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures

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

Lasers in contemporary oral and maxillofacial surgery

The practice of oral and maxillofacial surgery has included the use of lasers since the 1960s. Over the past few decades, the use of lasers among oral and maxillofacial surgeons has grown dramatically. Their evolution within the specialty not only has enhanced current surgical options for treatment, but also contributed to a variety of new procedures that are now commonplace in oral and maxillofacial surgery. The management of patients with sleep apnea, temporomandibular joint derangements, dental implants, premalignant lesions, and posttraumatic facial scarring has improved significantly with the advent of laser surgery. As the number of laser systems grows and their technology becomes more advanced, a thorough understanding regarding the principles of their use is paramount to providing safe and effective patient care.