Indications for palatopharyngoplasty

The Uvulopalatopharyngoplasty Operation: The Edinburgh Experience

The experience of the uvulopalatopharyngoplasty operation, performed on 24 patients for the relief of loud or heroic snoring, is presented. The operation successfully reduced the severity of snoring in 96% of patients. Postoperative complications were uncommon but included nasal regurgitation and intrapharyngeal adhesions in one patient. The role of the uvulopalatopharyngoplasty operation in the treatment of obstructive sleep apnoea is undecided but the authors do not perform this operation on such patients.

Prosthodontic approach to treat obstructive sleep apnea

Sleep disordered breathing represents a continuum, ranging from simple snoring sans sleepiness, upper-airway resistance syndrome, obstructive sleep apnea (OSA) syndrome, to hypercapnic respiratory failure. Fifty seven articles formed the initial database and a final total of 50 articles were selected to form this review report. Four months were spent on the collection and retrieval of the articles. Articles were selected based on accuracy and evidence in the scientific literature. Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or for those who do not respond to, are not appropriate candidates for, or for those who have failed treatment attempts with CPAP. OAs protrude the mandible and hold it in a forward and downward position. As a consequence, the upper airway enlarges antero-posteriorly and laterally, improving its stability. Although OA are effective in some patients with OSA, they are not universally suitable. Compliance with OAs depends mainly on the balance between the perception of benefit and the side effects. In conclusion, marked variability is illustrated in the individual response to OA therapy and hence the treatment outcome is subjective.

Influence of body mass index on treatment of breathing-related sleep disorders

Background

Breathing-related sleep disorders cover several conditions (isolated snoring, UARS - upper airway resistance syndrome, obstructive sleep apnea, hypopnea, obesity hypoventilation syndrome) characterized by a variety of symptoms and complex etiology. The conditions can be successfully treated in most cases. Excessive body mass is a factor increasing the probability of the disorders. In most patients it is the only reason for breathing-related sleep disorders. However, it often coexists with various anatomical abnormalities in the upper airway, endocrinological diseases or genetic defects of the facial skeleton, and occurs more frequently in older people, especially men. Excessive body mass significantly affects the range and success of the treatment.

Objective

To analyze treatment outcome in patients treated at the otolaryngology unit for snoring and related diseases with submucosal tissue reduction within the nasal cavity, pharynx, and soft palate.

Materials and methods

Patients were stratified into three study groups depending on the body mass index (BMI): normal, overweight, and obese. The BMI value was compared to the severity of breathing disorders during sleep, with the incidence of other systemic diseases (e.g., hypertension, diabetes), and with treatment outcome.

Results and conclusions

The analysis demonstrated a significant influence of body mass on snoring, particularly in complicated and severe types of breathing disorders, such obstructive sleep apnea or hypopnea, and the obesity hypoventilation syndrome. Corrective interventions carried out to eliminate anatomical abnormalities causing obstruction of upper airways provided the best therapeutic effects in patients with normal body mass.

Diagnostic Studies in Obstructive Sleep Apnea

The standard for the diagnosis of obstructive sleep apnea (OSA) is polysomnography (PSG). Although PSG helps identify individuals who have OSA and guides medical management, it does not identify the obstruction site or predict surgical results. Radiologic and diagnostic studies have been used to direct surgical intervention and predict outcomes of sleep apnea surgery. These studies include lateral cephalometric radiographs, CT, MRI, asleep fluoroscopy, asleep and awake endoscopy, upper airway manometry, and acoustic reflection techniques. The ideal diagnostic study would identify individuals who have OSA, be cost-effective and readily accessible, and guide therapeutic, site-specific intervention with predictable results. In this article, the various modalities are reviewed in terms of their capability to effectively diagnose and guide treatment of OSA.

Bipolar radiofrequency treatment for snoring with mild to moderate sleep apnea: a comparative study between the radiofrequency assisted uvulopalatoplasty technique and the channeling technique

We compared radiofrequency techniques used in the treatment of snoring and obstructive sleep apnea [radiofrequency assisted uvulopalatoplasty (RAUP) and channeling] as regard the efficacy and morbidity. A pilot, prospective randomized single blinded study was conducted on 40 patients in the ENT Department, Kasr Al-Aini Hospital, Cairo University during the period from April to December 2003. Patients were randomized into two groups each consisting of 20 patients. The first group was treated by submucosal channeling of the palate, while the second group was treated by radiofrequency assisted uvulopalatoplasty (RAUP). Patients were followed for 4 months, filling a questionnaire in a standard visual analogue score pattern. Assessment was done prior to the surgery and was repeated 3, 10 days and 3 weeks postoperatively. Visual analogue scores were done for the following parameters: pain, speech deficits, dysphagia, and snoring (by the bed partner). Polysomnography was done pre to intervention and was repeated 4 months postoperatively. This work confirms the favorable effects of radiofrequency in the treatment of patients with snoring and mild to moderate obstructive sleep apnea (OSA) particularly on snoring, confirming the results of the previous studies and highlighting the more rapid relief of snoring and apnea in RAUP group compared to channeling group but with more postoperative pain and morbidity.

Can anatomical and functional features in the upper airways predict sleep apnea? A population-based study in females

CONCLUSION

The importance of clinical findings in the nose and throat, including fiberoptic endoscopy during the Muller maneuver, in predicting sleep apnea is greater in normal-weight than in overweight women.

OBJECTIVES

The aim of this study was to identify clinical features that could predict sleep apnea in women.

METHOD

From 6817 women who previously answered a questionnaire concerning snoring habits, 230 women who reported habitual snoring and 170 women from the whole cohort went through a full-night polysomnography. A nose and throat examination including fiber endoscopic evaluation of the upper airways during the Muller maneuver was performed in a random selection of 132 women aged 20-70 years.

RESULTS

Sleep apnea was defined as an apnea-hypopnea index of > or = 10. The influence of clinical features on the prevalence of sleep apnea varied between normal-weight and overweight women. A low soft palate, retrognathia, the uvula touching the posterior pharyngeal wall in the supine position, and a 75% or more collapse at the soft palate during the Muller maneuver were all significant predictors of sleep apnea in women with a body mass index (BMI) < 25 kg/m2 but not in overweight women.

The Effect of Surgical Treatment of Obstructive Sleep Apnea Syndrome on the Plasma TNF-.ALPHA. Levels

Obstructive sleep apnea syndrome (OSAS) is defined as intermittent complete or partial upper airway obstruction during sleep, causing mental and physical effects. Both the local and systemic inflammation observed in OSAS induce certain potent pro-inflammatory mediators, which may contribute to the development of cardiovascular consequences. The present study was designed to evaluate the plasma levels of TNF-alpha, which is one of the known pro-inflammatory cytokines, in patients with OSAS and to assess the effect of surgical treatment on the levels of TNF-alpha levels. Twenty seven patients diagnosed to have OSAS, 7 non-apneic patients with chronic tonsillitis (non-OSAS patients), and 4 healthy subjects were enrolled in this study. Blood samples were collected one week preoperatively and postoperatively, and the plasma TNF-alpha levels were measured using high-sensitivity ELISA. The plasma TNF-alpha levels in patients with OSAS were significantly elevated in comparison to normal healthy subjects. In contrast, there was no difference between the patients with non-OSAS and healthy subjects. Moreover, the surgical treatment to enlarge the upper airway in patients with OSAS significantly decreased the levels of TNF-alpha levels. Surgical treatment of patients with OSAS reduces the plasma TNF-alpha levels, thereby ameliorating the systemic inflammation and preventing the development of cardiovascular consequences.

A review of surgical treatment for obstructive sleep apnoea/hypopnoea syndrome

Surgical intervention and treatment of OSAHS and snoring has a considerable history, encompassing a number of operations all of which have the intention of reducing or by-passing the pharyngeal resistance that occurs during sleep. Review of the published literature presents some problems, however, due to the ethical difficulties of undertaking randomised controlled trials in surgery. Uncontrolled trials are less satisfactory due to the large 'regression to the mean' and placebo effects. However, there is a considerable body of literature available relating to surgical intervention.

The limitations of isolated palatal surgery for patients with obstructive sleep apnea

Obstructive sleep apnea is a condition for which palatal surgery in isolation has been shown to have limited success. In comparison, palatal procedures combined with other surgical approaches that address the multiple sites of obstruction in the upper aerodigestive tract seem to have improved success in the carefully selected patient.

[Clinical and functional analysis of long-term results of uvulopalatopharyngoplasty]

In order to evaluate the clinical and functional effectiveness of uvulopalatopharyngoplasty (UPPP) in chronic roncopathy, we studied the subjective improvement of operated patients and compared to pulsioximetry findings before and after surgery. A follow-up was made on 72 patients entitled of chronic roncopathy--51 with obstructive sleep apnea syndrome (OSAS) and 21 with simple snoring-, for a mean period of time of 41 months. Preoperatory study included on ENT exploration, fibre optic endoscopy, Müller maneuver, pharyngeal CT, value of daytime sleepiness with Epworth's scale, espirometry and pulsioximetry, and the postoperatory study included of pulsioximetry and a health questionnaire over snoring and daytime sleepiness. Snoring improved or disappeared in 13 of 21 patients (61.8%), and daytime sleepiness did it in 26 of 39 (66.6%). Therapeutic failure in snoring was mainly due to an increase in the body mass index. After UPPP in OSAS, only 21 patients (41.1%) showed all positive response criteria (decrease into ODI > or = 50% or in absolute values < 6, CT 90% < 1%, and SaO2 Min > or = 85%). UPPP failed in long term evaluation in the rest of individuals. Patient selection is mandatory to optimize clinical response of UPPP for snoring, without OSAS success depends on body mass index, respiratory disturbances ratios and the eventual presence of another upper airways collapses below velopharyngeal segment.

Long-term follow-up of obstructive sleep apnea syndrome following surgery in children and adults

Obstructive sleep apnea syndrome (OSAS) is characterized by recurrent apneas during sleep, resulting in repetitive hypoxemia. The present study retrospectively analyzed subjective and objective assessments of the patients with OSAS in a relatively long-term follow-up. From February 1986 to August 1996, 53 patients received surgical treatment for OSAS and snoring. Thirty-seven (27 males and 10 females) out of 53 patients completed the questionnaire and postoperative sleep study was obtained in 6 patients. In 20 children (<15 years), snoring, sleep apnea, and daytime sleepiness completely disappeared in 12, 19, and 16, and improved in 8, 1, and 4, respectively. These findings confirm that tonsillectomy and/or adenoidectomy in children may be the first selection for treatment. In 17 adults, snoring, sleep apnea, and daytime sleepiness completely disappeared in 2, 5, and 8, improved in 11, 8, and 7, and was unchanged in 4, 4, and 1, respectively. The apnea index in adults was significantly decreased in both early and late postoperative periods. These results suggest that surgery is a satisfactory alternative for adult patients if performed accurate preoperative diagnosis of the localization of the airway collapse and careful long-term follow-up.

Management of tongue base obstruction in obstructive sleep apnoea syndrome

Studies have shown that the obstruction in OSA is more often than not multicentric. Tongue base obstruction is relatively more difficult to diagnose accurately and treat effectively. In this presentation, an effort is made to suggest two methods of management of this problem. One deals with the surgical management and the second, an alternative non-surgical method.

Patient selection and surgical results in obstructive sleep apnea

In recent years, therapeutic methods have been effective in the management of snoring and sleep apnea. Successful results have been possible through conservative and surgical approaches when the nature and site of obstruction is ascertained by careful investigation. Sagittal magnetic resonance imaging (MRI) of the upper respiratory tract has been the most valuable diagnostic tool in patients with obstructive sleep apnea. This has made it possible to measure the dimensions and distance of the hard and soft palate and tongue base to the posterior pharyngeal wall. Surgery is only indicated when a site of obstruction can be completely determined. In this study, surgical approaches and results obtained in 50 patients after surgery for sleep apnea are presented. Uvulopalatopharyngoplasty (UPPP) had a higher success rate in patients with obstruction at the level of the soft palate, but this rate decreased when it was associated with hypopharyngeal obstruction or when there was hypopharyngeal obstruction alone. UPPP was found to be beneficial in patients with central apnea. Nasal pathologies also played an important role in sleep apnea. Better results were obtained when UPPP was performed in patients who were young, not obese and an apnea-hypopnea index was below 40. Some unusual pathologies included lingual tonsil hypertrophy in the adult, sublingual dermoid cysts and angioma of soft palate and were found to be the cause of OSA. After surgical excision of these pathologies, apneic periods disappeared.

Laser-assisted uvulopalatoplasty with Nd:YAG laser for sleep disorders

We evaluated the apnea index (AI), the oxygen saturation above 95% (SA95), the lowest oxygen saturation (LSAT), and snoring before and after laser-assisted uvulopalatoplasty (LAUP) in 106 patients with obstructive sleep apnea syndrome (n=59) or snoring (n=47). Type 1 LAUP was performed in 42 patients and type 2 LAUP in 64 patients. A 50% or greater reduction in AI was observed in 15 patients (35.7%) who underwent type 1 LAUP and 37 patients (57.8%) who underwent type 2 LAUP. Snoring was diminished in 18 (51.4%) of 35 patients who underwent type 1 LAUP and 30 (55.6%) of 54 patients who underwent type 2 LAUP. SA95 and LSAT showed no difference. No serious complications such as significant bleeding, postoperative episodes of asphyxia, nasopharyngeal stenosis, or nasal regurgitation were observed. LAUP was an effective outpatient treatment.

Previous tonsillectomy as prognostic indicator for success of uvulopalatopharyngoplasty

Factors that determine a successful outcome following uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA) are not well defined. This study was undertaken to determine if prior tonsillectomy is predictive of a lower response rate to UPPP. A retrospective review of a cohort undergoing UPPP alone or in combination with nasal septoplasty for OSA was undertaken. Preoperative and postoperative polysomnograms were obtained to evaluate the severity of the OSA. The sample was a consecutive series of 79 patients with OSA. Clinical evaluation was performed by both an otolaryngologist and a pulmonologist. Surgical treatment in this group of 79 patients included 52 UPPP and 27 UPPP in patients with prior tonsillectomy. Concurrent septoplasty was undertaken in 17 patients. Criteria for outcome were based on comparison of preoperative and postoperative polysomnograms (i.e., apnea index, respiratory disturbance index change, and lowest saturation). A response to therapy was defined as a reduction in apnea index greater than 50%. A success was defined as apnea index less than 5, reduction of respiratory disturbance index greater than 50%, and nadir saturation greater than 82%. In 79 patients with OSA, 78% responded and 37% reflected therapeutic successes. Patients with history of prior tonsillectomy were less likely to have therapeutic improvement following UPPP. In 52 patients without previous tonsillectomy, 88% responded and 52% had a successful outcome. Of those with previous tonsillectomy, 59% responded and 7% had a successful outcome. The status of previous tonsillectomy is an important prognostic indicator in the success of UPPP for the treatment of OSA. We speculate that the presence of palatine tonsils allows the removal of an extra measure of oropharyngeal tissue, thereby improving the likelihood of success for UPPP.

Respiration in NREM and REM sleep after upper airway surgery for obstructive sleep apnoea

To verify whether upper airway surgery in obstructive sleep apnoea syndrome affects differently respiration in NREM and REM sleep, 22 patients were studied by polysomnography before and three months after surgical treatment. On the average, treatment improved respiration during both sleep states, but no significant interaction was found between sleep state and effect of surgical treatment. According to the response to treatment, three groups of patients were identified: the first group (N = 6), with an improvement in apnoea-hypopnoea index (AHI), percentage of sleep time spent in apnoea and hypopnoea (time in AH) and mean oxyhaemoglobin saturation (SaO2) in both NREM and REM sleep; the second group (N = 5), with an improvement in AHI only in NREM sleep, associated with improvement in mean SaO2 in both sleep states; the third group (N = 11), without any improvement in AHI and time in AH, either associated (N = 5) or not (N = 6) with an improvement in mean SaO2 in both sleep states. An increase in the percentage of hypopnoeas out of the total AHI after treatment could partly account for the apparent discrepancy between AHI and mean SaO2 behaviour in the subjects of the second group, but not in the patients of the third group who improved their mean SaO2. Mixed apnoeas occurred before surgery in six subjects; they remained numerous after surgery only in two subjects who did not show any SaO2 improvement. In conclusion, the degree of improvement in respiration after upper airway surgery was similar in every patient in NREM and REM sleep.

Anaesthesia for laser pharyngoplasty--a comparison of the tracheal tube with the reinforced laryngeal mask airway

A common cause of snoring is palatal flutter which occurs when turbulent air flow causes the flexible soft palate to flutter. Surgical correction involves either removal of the soft palate or a reduction in its flexibility. Laser pharyngoplasty is a new surgical procedure designed to stiffen the soft palate. It presents a unique combination of problems for the anaesthetist. In this paper we describe the evolution of the anaesthetic technique for laser pharyngoplasty and analyse the results of the first 165 cases. Points of particular interest include the use of the reinforced laryngeal mask airway compared with the tracheal tube and late onset pain.

Predictors of outcome for uvulopalatopharyngoplasty

The objective of this study was to assess the value of preoperative fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM) and cephalometric radiography in predicting response to uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome. Fifty-three such patients having significant obstruction at the soft palatal level and variable degrees of obstruction at the base-of-tongue level underwent both diagnostic procedures before UPPP. Outcome was assessed by the apnea-plus-hypopnea index (AHI) as determined by polysomnography, which was performed before and after surgery. As a group, patients exhibited a significant 10-point reduction in AHI (46.5 to 36.7). However, 17 (32.1%) were judged to be responders as defined by a reduction of the AHI by an increment of 50% or greater with respect to baseline. Of all the cephalometric variables assessed, soft palate length was the only one that differed between responders and nonresponders (45.5 mm versus 42.6 mm, respectively). However, this difference only approached significance (P = .067). Similarly, FNMM results did not discriminate between responders and nonresponders. These results indicate that preoperative cephalometric radiography and FNMM cannot be reliably used to enhance surgical success.

Short- and long-term outcomes of uvulopalatopharyngoplasty for snoring

Uvulopalatopharyngoplasty is a well established and highly successful operation in the treatment of snoring. However, most published data are based on relatively short-term follow-up results. Anecdotal cases of late recurrence of snoring after an initially successful surgical result have been reported but few formal studies have been performed to determine the true magnitude of this problem. We compared the short-term and long-term results on our patients and found the late recurrence rate after a minimum follow-up period of 12 months (range: 12-84 months, mean 31.3 months) to be in the region of 13%. The risk of recurrence was directly related to the body mass index.

Predictive value of Müller maneuver, cephalometry and clinical features for the outcome of uvulopalatopharyngoplasty. Evaluation of predictive factors using discriminant analysis in 30 sleep apnea patients

The success rate of uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea is generally only 50-60%. In order to improve this, various predictive factors for the outcome of UPPP were studied, including the Müller maneuver and cephalometry. Thirty unselected consecutive patients with obstructive sleep apnea (median apnea index (AI) 26 apneas/h, range 5-78) underwent UPPP with standard tonsillectomy except in the case of small tonsils and using CO2 laser for the palatal resection. Polysomnographic control 5 months after surgery showed that 63% of all patients had obtained a reduction in AI > or = 50% including an AI < 20 after surgery. Tonsillectomy had no influence on the outcome. Further, the Müller maneuver did not predict the outcome, whereas cephalometry proved to be of good predictive value. Lowered position of the hyoid bone, increased cranio-cervical angle and shortening of the maxilla length were significantly associated with poor results of UPPP, as were overweight, narrowing of the hypopharynx, the severity of sleep apnea, and hypersomnia. However, in a discriminant analysis containing all these variables, the three cephalometric measurements together with hypersomnia were most closely associated with the outcome of UPPP. A predictive model containing these four variables could correctly classify 83% of the patients in the present study. The model had a false positive rate of 7% in predicting a successful outcome. This indicates that cephalometry is mandatory in the selection of UPPP candidates and that a predictive model containing some or all of the four variables may substantially improve the success rate.

Site of pharyngeal narrowing predicts outcome of surgery for obstructive sleep apnea

Uvulopalatopharyngoplasty (UPPP), an operation that enlarges the pharyngeal airway at the level of the soft palate, improves respiratory status during sleep in only 50% of patients with obstructive sleep apnea (OSA). This poor outcome suggests that narrowing of the pharyngeal airway at nonpalatal sites contributes to the obstructive process in many patients with OSA. We have used a novel endoscopic method to identify regions of the passive pharyngeal airway most susceptible to narrowing or complete closure. In order to test the hypothesis that narrowing of the passive airway at the nasopharynx predicts a favorable surgical outcome, we have preoperatively assessed the local mechanics of the passive pharyngeal airway in 18 patients with OSA undergoing UPPP. The patient population was prospectively divided into two groups: an exclusively nasopharyngeal (ENP) group, consisting of patients exhibiting narrowing only in the nasopharynx, and a not exclusively nasopharyngeal (NENP) group, consisting of patients having at least one site of narrowing outside the nasopharynx. The frequency of respiratory disturbances and arousals and the cumulative time in apnea-hypopnea were significantly reduced after surgery for the ENP group, but not for the NENP group. Improvement rate for the ENP group (86%) exceeded that for the NENP group (18%) (p < 0.01). These differences became even greater when selection criteria for the ENP group were made more restrictive (i.e., restricted to the velopharynx) or more liberal (i.e., including secondary narrowing of the oropharynx). Our results show that evaluation of passive pharyngeal mechanics identifies patients with OSA likely to improve after UPPP.

Palatopharyngoglossoplasty in the treatment of patients with obstructive sleep apnea syndrome

A new technique (palatopharyngoglossoplasty (PPGP)) has been developed for surgical treatment of patients with the obstructive sleep apnea syndrome (OSAS). In 20 operated patients 18 reported immediate marked improvement of daytime sleepiness, alertness and vigilance during the day, and of working capacity. However, polysomnography carried out pre- and postoperatively showed that only 10 patients were "cured", defined as 50% or more reduction in apnea/hypopnea index (AHI). Cephalometric analysis pre- and postoperatively indicated that nonresponders had a long and narrow posterior airway space, and we suggest that during sleep this part of the upper airway collapses before as well as after the operation. The discrepancy between the subjective improvement observed after PPGP and the postoperative reduction in AHI may be due to reduced/eliminated snoring and/or improvement in sleep quality after the operation.

A comparison of sleep nasendoscopy and the Muller manoeuvre

Knowledge of the level of pharyngeal obstruction during sleep is an important factor in deciding whether or not a patient suffering from obstructive sleep apnoea syndrome (OSAS) will benefit from uvulopalatopharyngoplasty. The Muller manoeuvre has been advocated as a method of obtaining this information. We compared the findings from the technique of sleep nasendoscopy, which actually allows visualization of the level of obstruction in the sleeping patient, with the results of the Muller manoeuvre performed in the same patients while awake. We found the Muller manoeuvre to be less accurate than previously believed.

Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea

It appears that uvulopalatopharyngoplasty (UVPP) is a reliable procedure for reducing snoring, but much less reliable when used as a treatment for OSAS. This is thought to be because of poor patient selection in that the site of the problem is not always the site of the operation. We present the technique of sleep nasendoscopy which allows direct visualization of the site or sites of obstruction in a sleeping patient. Our study has shown that there are patients with obstructive sleep apnoea syndrome (OSAS) in whom the only site of pharyngeal obstruction is at the velopharynx. These patients should do well with the relatively simple procedure of UVPP. This is not true for many other OSAS patients in whom we found that obstruction was multisegmental. This helps to explain the frequently poor results of UVPP in OSAS patients. We feel that this form of preoperative assessment will avoid unnecessary surgery.

Obstructive sleep apnea: a comparison of continuous positive airway pressure and surgical treatment

Since earlier descriptions of the syndrome of obstructive sleep apnea (OSA), various treatment alternatives have included a variety of medical regimens, continuous positive airway pressure (CPAP), tracheostomy, and other surgical options. A lack of acceptable criteria for surgical intervention remains an important concern for the surgeon. in an attempt to resolve some of the controversies pertaining to various therapeutic modalities, we performed a retrospective analysis--from 1983 to the present--of posttreatment results in patients who underwent surgical therapy and those who were treated primarily with CPAP at this institution. Of 400 patients diagnosed with OSA, only 66 underwent surgical treatment, including uvulopalatopharyngoplasty. CPAP was the mainstay of treatment in the majority of our patients. Post-treatment data were available for 50 patients treated with CPAP and for 45 patients treated surgically. A comparative analysis of polysomnographic studies revealed superior cures with CPAP, although long-term compliance remains a significant problem. We advocate CPAP as initial therapy in patients with no clinically apparent causes for obstruction (e.g., nasal polyps, deviated nasal septum, or obstructive tonsillar hypertrophy) because of the predictability of success, and lower costs and complication rates. Long-term followup of OSA patients is indicated, regardless of treatment modality.

Laser uvulopalatoplasty in treatment of habitual snoring

Velopharyngeal sonorous snoring is best treated with uvulopalatopharyngoplasty (UPPP). To reduce surgical risks and minimize the morbidity, a simplified carbon dioxide laser uvulopalatoplasty (LUPP) was performed under local anesthesia. Among a total of 146 patients who had a LUPP performed, there was no significant bleeding or postoperative episodes of asphyxia. The procedure was well tolerated even by those patients with strong vomiting reflexes. The operation time was halved, as was the convalescence. Two patients (1.4%) developed scarring with nasal obstruction, but the impact of factors other than the laser approach itself seemed to be the cause. By scored questionnaires the effect on snoring, family complaints, and daytime somnolence was evaluated in two comparable random groups of patients. Sixty-three patients had LUPP procedures, and 37 had UPPP. The short-term results showed that about 90% of the patients considered themselves essentially improved as regarded snoring and that most patients felt more alert, irrespective of the surgical method used.

Uvulopalatopharyngoplasty in obstructive apnea. Value of preoperative localization of site of upper airway narrowing during sleep

We hypothesized that those obstructive sleep apnea (OSA) patients with upper airway collapse during sleep within the transpalatal airway would have a more favorable response to uvulopalatopharyngoplasty (UPP) than those patients with obstruction within the hypopharyngeal airway. We tested this hypothesis in seven OSA patients with transpalatal and seven with hypopharyngeal obstruction undergoing UPP. Preoperatively the apnea/hypopnea index (AHI) was different between palatal and hypopharyngeal obstructors, 37.8 +/- 6.0 (+/- SEM) and 63.9 +/- 6.3, respectively (p less than 0.05), but the apnea-associated arterial oxygen desaturation and the lowest sleep saturation level were not different between the two groups. Postoperatively the AHI was 17.6 +/- 7.2 in the palatal obstructors and 40.3 +/- 15.6 in the hypopharyngeal obstructors (both p less than 0.05 from preoperative AHI). The palatal obstructors had a significant decrease in the percentage of sleep time spent apneic and the hypopharyngeal obstructors had a significant decrease in the hypopnea, but not apnea, time following surgery. The palatal obstructors had a significantly higher postoperative arterial oxygen saturation than the hypopharyngeal obstructors. Two hypopharyngeal obstructors worsened postoperatively. In addition we found that regardless of the site of the obstruction preoperatively, all obstructions occurred at the level of the palate postoperatively. We conclude that patients with preoperative transpalatal obstruction had diminution in obstructive apneas and those with hypopharyngeal obstruction had diminution in hypopneas but not apneas. Oxygenation was better postoperatively in the palatal obstructors, and none worsened postoperatively. These results suggest that identification of the site of upper airway obstruction in OSA may be beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)

Uvulopalatopharyngoplasty for treatment of obstructive sleep apnea

Currently, uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure used for the treatment of obstructive sleep apnea. Patients with clinically significant obstructive sleep apnea in whom medical treatment has failed or who are unwilling to comply with medical therapy are considered candidates for UPPP. The initial surgical results obtained in nonselected patients with obstructive sleep apnea were highly variable, approximately half of the patients experiencing more than a 50% reduction in the frequency of disordered breathing events postoperatively. Although differences in surgical technique likely account for some of the variability, preoperative differences in the site (or sites) of upper airway collapse are also thought to influence the surgical results. Because UPPP involves resection of the uvula, distal margin of the soft palate, palatine tonsils, and any excessive lateral pharyngeal tissue, patients with anatomic narrowing and collapse confined to the velopharyngeal or retropalatal region of the upper airway are considered optimal surgical candidates. Fiberoptic pharyngoscopy, cephalometric roentgenography, computed tomography, and somnofluoroscopy are procedures that can be used preoperatively to help select optimal candidates for UPPP. The results suggest that the success rate of UPPP can approach 66% with careful preoperative selection of patients.

[Effects of uvulopalatopharyngoplasty in adult patients with obstructive sleep apnea syndrome]

We performed uvulopalatopharyngoplasty (UPPP) in 51 adult patients with obstructive sleep apnea syndrome (OSAS). After UPPP, there were statistically significant improvements in apnea-hypopnea index (AHI), the lowest value of oxygen saturation during sleep and total time of apnic episodes. 28 patients (54.9%) were good responders who represented more than 50% improvements in their AHI. Poor responders tended to be more severe and older than good responders. After cephalometric analysis, poor responders were revealed to show significantly poor mandibular prognatism and also lower positioned hyoid bone than good responders.

Uvulopalatopharyngoplasty: postoperative management and evaluation of results

Since the earliest report of success with the uvulopalatopharyngoplasty (UPPP) operation, several authors have reported less than optimal results in their experience with the procedure. Part of the difficulty in evaluating the objective results of postoperative sleep studies has been the variations in reporting data. In addition, no standard of postoperative care, including analgesia, and immediate postoperative monitoring has been described. Our experience with 42 UPPP patients (34 studied with preoperative and postoperative polysomnography) indicates a 76% response (56% successes, and an additional 20% with limited success) with use of the more stringent criteria described recently. We discuss our management of these cases, including postoperative oxygen saturation monitoring and avoidance of narcotic analgesia as necessary factors for success with this operation.

Cephalometric analysis in patients with obstructive sleep apnoea syndrome: II. Soft tissue morphology

Oropharyngeal soft tissue profiles were studied by cephalometric analysis in 25 patients with obstructive sleep apnoea syndrome (OSAS) and 10 controls. The length of the soft palate was significantly higher in patients (48.0 +/- 4.3 mm. (mean +/- SD) than in controls (35.3 +/- 4.6 mm.) (p less than 0.001), as was the distance of close contact between the tongue and the soft palate (23 +/- 12 mm. and 10 +/- 8 mm., respectively) (p less than 0.01). The area of the soft palate, measured in the sagittal plane, was 4.85 +/- 0.80 cm.2 and 2.88 +/- 0.62 in the patient and the control group, occupying 39 +/- 8 per cent and 21 +/- 5 per cent of the pharyngeal area (p less than 0.001). The lower outline of the tongue, represented by the line between vallecula (V) and the hyoid bone (AH) was more inferiorly positioned in patients, apparently giving the tongue a more upright position with more of the tongue tissue at the hypopharyngeal level than found in normals. The pharyngeal airway space had significantly reduced anteroposterior dimensions both at the nasopharyngeal and velopharyngeal level (P less than 0.001) as well as the hypopharyngeal level (p less than 0.05). Cephalometric analysis is highly recommended as a valuable tool in the presurgical evaluation of OSAS patients.

Cephalometric analysis in patients with obstructive sleep apnoea syndrome. I. Skeletal morphology

Facial skeletal morphology was studied by cephalometric analysis in 25 patients with obstructive sleep apnoea syndrome (OSAS) and ten controls. The hyoid bone was more inferiorly positioned in patients (at the level of cervical vertebrae C4-C6) than in controls (C3-C4 level). The height and length of the nasal cavity was normal, while the length of the bony nasopharynx was moderately reduced. The mandibular plane inclination was slightly larger in patients as was the anterior face height. Mandibular retrognathia was demonstrated in six patients (24 per cent), but the angles of maxillary and mandibular prognathism was within normal limits when the group was considered as a unity. Cephalometric analysis is highly recommended as a diagnostic aid in OSAS patients, especially when surgical intervention is considered.

Uvulopalatopharyngoplasty in severe idiopathic obstructive sleep apnoea syndrome

Eleven patients with severe obstructive sleep apnoea syndrome, which was fully reversed by treatment with nasal continuous positive airways pressure, underwent uvulopalatopharyngoplasty. All patients were followed for at least 12 months after surgery. One patient with large tonsils was cured. Of the remaining 10 patients, two showed minimal objective improvement at 12 months and the rest were unchanged. Four patients subsequently developed cardiac failure due to obstructive sleep apnoea. Thus uvulopalatopharyngoplasty was not effective in these patients with severe idiopathic obstructive sleep apnoea syndrome.

Uvulopalatopharyngoplasty as a treatment for snoring

Uvulopalatopharyngoplaty was performed in 18 consecutive patients (15 men and three women; mean +/- standard deviation [SD] age, 46.3 +/- 7.5 years) who presented for the treatment of heavy habitual snoring. No attempt was made to select patients who were ideal anatomically for palatal modification. The loudness of snoring was measured during sleep by integrating the output of a calibrated microphone. An assessment before operation showed that nine patients had obstructive sleep apnoea; four patients had an apnoea index of greater than or equal to 25 apnoeas per hour. The patients were overweight and consumed, on average, 38 g of alcohol per day, but these variables did not change after the operation. The postoperative assessment was performed 138 +/- 44 days after uvulopalatopharyngoplasty. Fourteen patients showed a reduction in the loudness of their snoring, although snoring was abolished in one patient only (average snoring loudness in arbitrary units/min of sleep, 2.8 +/- 2.1 before operation compared with 1.4 +/- 1.5 units/min of sleep after the operation; P less than 0.05. The loudest snore in arbitrary units measured 7.1 +/- 3.3 units compared with 4.8 +/- 3.3 units, respectively; P less than 0.05). The percentage of the sleep time that was spent at an arterial oxygen saturation of less than 90% was reduced after uvulopalatopharyngoplasty (28% +/- 32% of total sleep time compared with 17% +/- 24% of total sleep time, respectively; P less than 0.05). There was no change in the apnoea index. The diastolic blood pressure was lower at the postoperative assessment (94 +/- 11 mmHg compared with 87 +/- 8 mmHg; P less than 0.05); six of 10 subjects whose diastolic blood pressures were greater than or equal to 95 mmHg before the operation had a diastolic blood pressure of less than 95 mmHg after uvulopalatopharyngoplasty (P less than 0.02). Computed tomographic scans showed an increase in the upper airway cross-sectional area at 3 cm and 4 cm above the hyoid bone after uvulopalatopharyngoplasty (P less than 0.05). We conclude that uvulopalatopharyngoplasty is an effective treatment for habitual, heavy snoring in many patients, but it is not the treatment of choice for patients with clinically-significant obstructive sleep apnoea.

The effect of a modified functional appliance on obstructive sleep apnea

This study combined the use of cephalometrics and overnight polysomnographic monitoring to analyze the effects of a modified functional appliance on airway, sleep, and respiratory variables in patients with obstructive sleep apnea (OSA). Twelve patients without overt anatomic or pathologic evidence of obstruction were selected on the basis of an initial single night of polysomnographic monitoring, which confirmed the diagnosis of obstructive sleep apnea syndrome. The patients subsequently were fitted with a modified functional appliance designed to securely hold the mandible in an anterior-inferior position. A subsequent overnight polysomnographic study was obtained with each patient wearing the appliance. Lateral cephalometric radiographs with and without the appliance in place were also obtained. The mean vertical and horizontal changes in mandibular position while wearing the appliance were 8.49 mm and 2.28 mm, respectively. The findings indicate that 10 of the 12 patients had decreases in the rate of complete airway obstructions from a mean of 28.86 to 18.69 events per hour, and in the total apnea index from a mean of 53.81 to 35.99 events per hour. A reduction in the rate of obstructive events is attributed to the effect of the appliance on the oropharyngeal structures. Six cephalometric measurements are presented to provide a means of assessing effects of the appliance on the oropharynx and associated structures. The modified functional appliance is a conservative, successful treatment alternative that could benefit patients with obstructive sleep apnea syndrome.