Results of uvulopalatopharyngoplasty in snoring

Soft palate implants: a new option for treating habitual snoring

One hundred six patients with proven habitual snoring were each treated with three implants consisting of a cylindrical-shaped segment of braided polyester filaments (18 mm in length with an outer diameter of 1.5 mm) in the soft palate. The implants, pre-loaded in a single-use delivery tool, were inserted into the soft palate under local anesthesia. Along with the initial examination, follow-up exams were done after the treatment to test the safety and efficacy of the procedure. Snoring post treatment was reported as "no snoring" or "slight/occasional" in the majority of the cases after treatment. The results indicate there were no serious adverse events reported. The most frequent minor adverse events were partial extrusions in which the patient often presented a minor foreign body sensation along with mild transient pain. This data has demonstrated the procedure as a minimally invasive, relatively painless, simple procedure that has been shown to be safe and effective.

Radiofrequency volumetric tissue reduction of the soft palate: a new treatment for snoring

OBJECTIVE/HYPOTHESIS

Current options for the treatment of snoring have limited acceptance because of intolerance, expense, pain, or need for general anesthesia. A clinical trial using a new application of a previously known technology-radiofrequency energy-was investigated to determine its efficacy in the treatment of snoring. Effects of treatment on speech, swallowing, pain, snoring, and degree of sleepiness were evaluated. These effects were evaluated by post-treatment questionnaires.

METHODS

Prospective nonrandomized study. All included subjects snored at a level considered bothersome to their bed partner. A total of 43 patients were enrolled at the University of Maryland (UM) and the Georgia Ear Institute (GEI). Polysomnography was performed before treatment to eliminate patients with significant sleep apnea who had respiratory disturbance indices (RDIs) greater than 15 or nadir desaturations less than 80%. The mean pretreatment RDI for all patients who entered the protocol at UM was 6.7 +/- 4.7. Nine patients completed the study in this group in all other aspects, but did not return for their scheduled post-treatment polysomnogram. At GEI, pretreatment polysomnograms revealed a mean RDI of 8.9 +/- 3.8. Eleven patients at GEI completed the study in all other aspects but did not return for their scheduled post-treatment polysomnogram. Radiofrequency energy was delivered to the soft palate either in the midline (19 patients) at a mean of 698 +/- 52 J per treatment at UM or in the midline and lateral soft palate (24 patients) at a mean of 1,254 +/- 191 J per treatment at GEI. At UM the mean age was 44.3 +/- 8.4 years, with a range from 29 to 59 years. Eighty-four percent of the patients were men. The mean body mass index (BMI) was 28.5 +/- 3.2. Twenty-four patients were enrolled at GEI. The mean age was 44.0 +/- 10.9 years, with a range from 23 to 63 years. Seventy-four percent of patients were men. The mean BMI was 27.7 +/- 3.8. Snoring, pain, swallowing, and speech were assessed after each treatment at post-treatment day 1, 2, or 3; week 1; week 4; and week 7. Daytime sleepiness was assessed by the Epworth Sleepiness Scores (ESS) obtained at the same intervals.

RESULTS

Snoring was improved in 77% of patients after three treatments or less. Seventy-nine percent of patients treated with the midline technique at UM and 96% of patients treated with the midline and left and right lateral palate technique at GEI achieved an improvement in their snoring to a level that was no longer bothersome to their bed partner. No persistent negative impact was noted concerning speech or swallowing. Improvements in degree of sleepiness were observed by comparing pretreatment and post-treatment ESS. ESS was significantly reduced (P < .005) after treatment from 10.2 +/- 6.1 to 6.1 +/- 4.7 at UM, and at the GEI, from 8.75 +/- 4.4 to 5.3 +/- 3.2. After a treatment, 27% of the patients at UM and 29% at GEI required analgesics.

CONCLUSIONS

This clinical trial demonstrates the efficacy, safety, and lack of pain encountered when using radiofrequency energy delivered to the palate for the treatment of snoring. The tolerability, lack of pain, and ability to perform the procedure with the patient under local anesthesia in the office make the use of this technology an excellent option for the treatment of snoring.

Snoring, obstructive sleep apnea, and surgery

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, with or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction with contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity. Nonetheless, tracheostomy can be lifesaving and remains an option for patients with severe OSA with serious associated cardiovascular complications, who cannot tolerate CPAP, and for whom other interventions are ineffective or unacceptable. Effective surgical treatment of snoring has been accomplished with UPPP and LAUP. LAUP is less invasive, less morbid, more cost-effective, and better tolerated and is likely the most appropriate procedure for debilitating symptomatic snoring. Currently, LAUP is not recommended for the treatment of OSA, despite some efficacy in patients with mild OSA. Exclusion of OSA in patients undergoing LAUP for snoring is important.

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.

Objective assessment of snoring before and after laser-assisted uvulopalatoplasty

Laser-assisted uvulopalatoplasty (LAUP) is an outpatient staged surgical procedure for the treatment of snoring. Each patient undergoes a series of procedures with the end point being patient and bed partner satisfaction in most cases. The purpose of this study was to objectively evaluate the frequency, pattern, and volume of snoring in patients prior to and following each LAUP procedure. A sonographic device, SNAP, which records oronasal respiration, was used to assess patients at home. A digital analysis of the frequency, pattern, and volume was then performed. Twenty-seven patients have been completely evaluated with this recording device. The findings demonstrate that the LAUP procedure alters the snoring sound. The maximum, average, and velum-like respiratory noise loudness all showed a statistically significant decrease when comparing the preoperative snoring to the final recording after treatment was completed. In addition, the fundamental frequency of the snoring increased significantly after each LAUP procedure. No change was seen in the snoring index following treatment. These objective results correlated well with the subjective responses of the patients and their bed partners. These findings are consistent with the hypothesis that the LAUP procedure alters snoring in a favorable manner by both objective data and subjective accounts.

Laser-assisted uvulopalatoplasty for snoring and obstructive sleep apnea: results in 170 patients

Laser-assisted uvulopalatoplasty (LAUP) is a procedure for the treatment of snoring and, possibly, sleep apnea. Between July 1993 and December 1994, the authors prospectively evaluated 541 consecutive patients referred to their teaching hospital for possible LAUP to treat loud, disruptive snoring. Of these patients, 274 (51%) had one or more LAUP treatments. As of January 1995, LAUP treatment courses were completed in 170 patients. In this paper, the authors report preliminary results on the use of LAUP in these patients. Among the 170 patients, 105 (62%) had a diagnosis of snoring and 65 (38%) obstructive sleep apnea syndrome (OSAS) based on preoperative polysomnography. LAUP treatment in the snoring only patients resulted in complete or nearly complete elimination of snoring in 63 patients (60%), partial improvement of snoring in 30 patients (29%), and no improvement in 11 patients (10%). Of the 65 OSAS patients treated with LAUP, postoperative polysomnograms were obtained in 33 patients (51%). Surgical success was achieved in 16 (48%) of the 33 patients. However, 7 patients (21%) had repeat polysomnograms that were worse than their preoperative polysomnograms, and 5 patients (15%) had no significant change. The results of this study suggest that LAUP may be a viable surgical option for patients with snoring and mild sleep apnea.

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.