------------------------------------------------------------------------------ TITLE: LASER-ASSISTED UVULOPALATOPLASTY SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: SEPTEMBER 7, 1994 RESIDENT PHYSICIAN: Ramtin Kassir, M.D. FACULTY: Francis B. Quinn, Jr. M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." The first reference alluding to sleep disturbance was made in 1836 by Charles Dicken's in The Pickwick Papers. In 1906 Sir William Osler recognized this syndrome by describing a patient with obesity and hypersomnolence. Ikematsu described uvulopalatopharygoplasty as a surgical treatment for snoring in 1964 and this was later applied to obstructive sleep apnea (OSA) in 1981 by Fujita . Since that time many complex treatments including orthognathic surgery have been advocated for the treatment of OSA. Many have favored uvulopalatopharyngoplasty for treatment of snoring and OSA but several surgical morbidities have been noted. SLEEP APNEA AND SNORING Sleep apnea and snoring are common conditions affecting about 5- 10% of the adult male population in the United States. The incidence of OSA in the general population may be as high as 4%. Snoring, per se, is much more common and affects approximately 50% of males and 30% of females. It is probably the pre-clinical state for the development of OSA. Patients who snore may actually have OSA when strict sleep study guidelines are applied. Of these patients, a significant proportion demonstrates classic OSA type snoring, which is cresendo snoring with ventilatory pauses despite a respiratory effort. Most patients complain of tiredness, excessive daytime somnolence, headaches, and poor job performance. This may cause marital difficulties and may very well contribute to separation and divorce. Medical morbidities for those with sleep apnea are well recognized. These include: arterial hypertension, angina, myocardial infarction and stroke, memory difficulties, behavioral and affective changes, impotence, and automobile accidents resulting in severe trauma or death. Those who snore without apnea are also at risk for the above mentioned conditions. Obesity, male gender, and older age are important risk factors. Metabolic disorders such as hypothyroidism and acromegaly are also etiologic factors. Untreated sleep apnea syndrome is indeed associated with excessive mortality. The quality of life of these patients is affected mainly by excessive daytime somnolence and listlessness. This condition is made worse by the use of alcohol, sedatives, and other CNS suppressants. DIAGNOSIS The diagnosis of snoring is made primarily by examining the patient's history, much of which can be obtained from the patient's bed partner. The character and consistency of the snoring is reviewed to determine severity and possible sleep apnea. Each patient is given a detailed survey that investigates his or her medical condition, sleeping position, alcohol and sedative intake, and weight changes. The physical examination includes a complete evaluation of the nose, nasopharynx, oral cavity, oropharynx, hypopharynx, and larynx. Anterior and posterior rhinoscopy may detect mechanical obstructions either due to nasal septal deviation, turbinate hypertrophy, polyps, neoplasms, or other pathology. Often the soft palate is elongated and the uvula is much larger than normal. The tongue may be large and the oropharyngeal airway may be reduced due to redundant soft tissue. Flexible fiberoptic nasolaryngoscopy aids in the examination and permits the performance of the Muller maneuver, that is, inspiration against a closed nose and mouth (reverse valsalva) to create maximal negative pressure. The examiner then notes the level (nasopharynx, oropharynx, hypopharynx) of collapse of the airway. Sher and colleagues applied the Muller manuever in the preoperative evaluation of patients with OSA to identify those patients in whom greatest pharyngeal collapse was in the region of the tonsillar fossae and soft palate ( regions altered by uvulopalatopharyngoplasty). The mean apnea index was diminished in 72% of their patients and and 87% had greater than 50% reduction in apnea index. These results compared favorably with previous results from uvulopalatopharyngoplasty (UPPP) and the authors concluded that preoperative selection of OSA patients by this maneuver increased the likelihood of success of UPPP. Other methods of evaluation of the upper airway include radiologic imaging ( lateral cephalometric radiography, somnofluoroscopy, computerized tomography, cine computerized tomography, magnetic resonance imaging) and physiologic studies (complete flow volume curves, rhinometry, pharyngeal manometry). Lateral cephalometrics and conventional CT have the shortcomings of being static measurements of the upper airway that are not obtained during sleep. Lateral cephalometrics are important, however, for the identification and surgical approach to mandibular or maxillary deficiency. Sleep fluoroscopy, manometric testing, and cine CT have demonstrated utility by defining multiple potential sites of obstruction in OSA. To date, however, there is no preoperative test which can predict with certainty a successful result of UPPP. The best evaluation for the diagnosis and severity of OSA (central, obstructive, or mixed) is the sleep study (polysomnogram). It measures sleep; actual measurements include electroencephalography, electrooculography, electrocardiography, electromyography, respiratory effort, nasal and oral airflow, and oxygen saturation. All are used to define the sleep stages and discover any abnormalities of sleep. The polysomnogram also measures the number of respiratory events, their duration and effect on oxygen saturation. Respiratory events are traditionally defined as apneas (no airflow) and hypopneas (partial airflow). Both can cause arousals from sleep and significant oxygen desaturations. Thus, the most useful measure is the Respiratory Distress Index (RDI= apnea + hypopnea) which is the number of respiratory events per hour; normal is five or less. The RDI ( aka Apnea / Hypopnea index) alone does not define severity. The duration of events is important, but the largest duartion is a better measure of clinical severity than is the average duration. A more important measure is the oxygen saturation, which as with duration is best measured by the lowest oxygen saturation as opposed to the mean saturation. Finally, EKG changes must be noted. A run of ventricular tachycardia associated with an apnea will transform a study from the representation of mildly severe to markedly severe sleep apnea. PATHOPHYSIOLOGY The normal physiology of the upper airway actually may predispose individuals to OSA. In sleep, the upper airway is more collapsible than during wakefulness. Ventilation and inspiratory flow decrease, upper airway resistance increases, and arterial CO2 tension rises. The musles beneath the upper airway mucosa have a distinct respiratory function in sleep. During awake hours these muscles exert a high level of tonic activity and some minimal phasic increase in activity during inspiration. In sleep there is considerable loss in tonic activity as well as some decrease in phasic activity. OSA is characterized by collapse of the upper airway while the patient sleeps. This collapse occurs when the negative pressure within the pharynx exceeds the ability of its walls and musculature to resist collapse. Any narrowing along the upper airway ( bulky tissue such as large tonsils, a redundant soft palate and/or elongated uvula ) will increase the pressure and subsequently promote further narrowing or will require an increase in the velocity of airflow, further reducing intraluminal pressure (Bernoulli principle). The actual noise associated with snoring is created by vibration of the uvula, soft palate edge, and tonsillar pillars during obstructive breathing. TREATMENTS Nonsurgical- Various surgical procedures are used to improve the the functional patency of the airway, but, while remarkable successes are frequent, they are not uniformly predictable. Furthermore, some patients may not be acceptable candidates for surgery. The most common nonsurgical treatments for snoring and OSA include, weight loss, sleep positioning, avoidance of sedating and relaxing drugs, anti-snore devices, nasal airway treatment, pharmacologic agents, and positive airway pressure. Weight loss- Vigorous weight loss programs have been recommended in an attempt to reduce some of the soft tissue flabbiness and bulkiness that compromise the upper airway in the collapsible portion, where snoring and obstructive sleep breathing occurs (from nasopharynx to epiglottis). Most patients, however, are not physically active because of their chronic sleepiness and they often keep eating just to stay awake and feel better. Drugs- Since hypotonicity of the pharyngeal musculature during sleep is part of the pathogenesis of OSA, it is obvious that sedatives, relaxants, tranquilizers, antihistamines, antiemetics, narcotic analgesics, and alcohol aggravate this condition. Unfortunately, patients take such drugs in order to improve their restless sleep. Sleep positioning/Devices- Snoring "cures" vary widely, ranging from sewing a tennis ball into a snorer's pajama back to electric shock mechanisms that give the snorer an unpleasant jolt. Most of these remedies and devices are based upon some sort of sleep behavior modification, with the presumption that a person can be trained or conditioned not to snore. The snorer, however, has no control over snoring and if these devices do work it is probably because they keep the patient awake. Pharmacologic agents- Protriptylene, a tricyclic antidepressant, is currently used to keep the patient in lighter stages of sleep, in which apnea is least likely to be troublesome. Dose related side effects are the main limiting factors. Other stimulants, such as amphetamines, strychnine and theophylline have ben tried but seem less useful than protriptylene. Positive airway pressure- The airway can be kept patent with positive airway pressure. The most practical method of delivery is through a nasal mask with a continuous air flow coming from an air pump on the floor at the bedside. Continuous positive airway pressure (CPAP) therefore serves as an "air splint". It is highly effective and has almost replaced tracheotomy as the treatment of choice for extreme cases of OSA and for patients who would be poor candidates for uvulopalatopharyngoplasty. Patient compliance is a significant drawback as patients dislike the idea of sleeping with a mask strapped on their faces with a noisy air pump at the bedside. However, when faced with the alternativeof tracheotomy, the patient with severe apnea finds an understandable attraction to CPAP. Surgical - Nasal airway treatment- Improvement in the nasal airway ( allergy management, septal deviation, turbinate hypertrophy, etc.) can help some snorers and a few apneic patients. The "afrin test " ( long acting nasal decongestant spray in each nostril one half hour prior to bedtime and comparing apnea and snoring on spray and nonspray nights) helps to identify these patients. Tracheostomy- reserved for the severe case of OSA with O2 desaturation under 50%, especially with serious central component or cardiorespiratory problems. Uvulopalatopharyngoplasty- the surgical treatment of choice for snoring before the introduction of LAUP and the most common procedure for OSA. It consists of a maximal removal of the soft palate and tonsils, including the uvula. It is rarely indicated in the pediatric age group. Adenoidectomy and tonsillectomy are the main surgical procedures in this group. UPPP is not without risk. Postoperative complications include hemorrhage (2%), nasal regurgitation (20%-60%), and permanent velopharyngeal insufficiency (O.5%). Complications are also related to the impact of general anesthesia. Difficulties with intubation, postoperative arousal and respiration, cardiac arrythmia, unreliable airway, postoperative asphyxia and even death all occur (more so for patients with OSA). Subsequent 24 hour observation in an intensive care unit is advocated. Other rare surgical procedures for snoring and OSA include partial resection of the tongue, horizontal sliding osteotomies of the mandible, fixation of the hyoid bone to anterior mandibular arch, etc. LAUP (Laser-Assisted UvuloPalatoplasty) Anesthesia- the patient is operated on in a sitting position. A topical anesthetic (Cetacaine or Benzocaine is sprayed in the posterior oral cavity over the soft palate, tonsils and uvula. After 5 minutes, ~ 1-3 cc of 1% xylocaine with 1/100,000 epinephrine is injected into the base of the uvula and the juntion of the uvula and the soft palate bilaterally. Procedure- A CO2 laser with a special pharyngeal handpiece attached to its articulated arm is used. The tongue is retracted inferiorly with an ebonized tongue blade with an integrated smoke evacuation channel. Through and through full thickness trenches that measure 1-1.5cm on the free edge of the soft palate along both sides of the uvula with a focused beam in a continuous mode ( 15-20 watts) using the pharyngeal handpiece with a backstop tip. The patient is instructed to take a deep breath and the laser is activated during very slow exhalation to avoid inhalation of the plume. Shortening and thinning of the uvula are carried out with a "SwiftLase" flash mode ( Sharplan Lasers, Inc.), using 18-20 watts. The uvula is ablated to almost 90% of its original length and thickness. The overall surgical goal is to reduce the length and reshape the uvula and soft palate. Occasional light bleeding can be controlled with silver nitrate. Each session of LAUP takes 15-20 minutes to perform. After the procedure, the patient is then instructed to gargle with H20/H202 solution. The full treatment is spread over 3-5 sessions, spaced about 4-6 weeks apart. This allows for proper healing of the soft palate mucosa. The endpoint of LAUP occurs when snoring is significantly reduced or eliminated as reported by the patient or bed partner. To ensure proper velopharyngeal management of airflow during a variety of speech tasks, the patient's speech and resonance characteristics are evaluated prior to each procedure. Postoperative Instruction - Because the procedure is performed under local anesthesia over several sessions, patients usually report minimal pain and leave the office fully alert, able to speak, eat, and resume regular activity. A soft, bland diet with avoidance of citrus fruits and spicy meals is recommended. Viscous xylocaine, diluted peroxide mouth rinses, and hydrocodone are used to relieve sore throat. Prophylactic antibiotics are prescribed for every patients; steroids are not indicated. Complications - A moderate to severe sore throat that peaks at 3- 5 days and resolves at 7-10 days is the most common effect of LAUP. Mild bleeding ( ~ 3%) can occur which is controlled with AgNO3. Most series report no late or delayed bleeding. One series reported vasovagal episodes to the anesthetic injection in two patients. Results and Conclusions- Recent experience shows LAUP to be an effective method for treating patients with loud, habitual snoring. ( Preliminary data indicate an 85% significant reduction or elimination of snoring). This procedure, performed in the office under local anesthesia, has proved to be a safe and reliable method to relieve this sociomedical problem. It eliminates the expense of general anesthesia, operating room suite and recovery room charges and an expensive hospital stay in which patients are admitted to the intensive care unit overnight. Most patients evaluated for the treatment of snoring have polysomnography prior to LAUP (70% in one series ). Some physicians view polysomnography as mandatory prior to LAUP while others will obtain this test only if the history is suggestive of more than just habitual snoring. Various degrees of OSA or other sleep disorders are found in most of these patients. Multiple centers are currently analyzing the results of LAUP as related to OSA. -------------------------------------------------------------------------- BIBLIOGRAPHY 1. Maniglia AJ. Sleep Apnea and Snoring, on Overview. ENT Journal, January 1993 16-19. 2. Fairbanks DNF. Nonsurgical treatment of snoring and obstructive sleep apnea. Otolaryngology Head and Neck Surg, 100:6, June 1989, 633-635. 3. Young T. et al. The occurence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. 4. Koopman CF, Moran WB Jr. Surgical management of obstructive sleep apnea. Otolaryngologic Clinics of North America. Vol. 23, No.4, August 1990. 5. Papsidero MJ. The role of nasal obstruction in obstructive sleep apnea syndrome. 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