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Laser-Assisted Uvulopalatoplasty for Snoring: Medium- to Long-Term Subjective and Objective Analysis

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Laser-Assisted Uvulopalatoplasty for Snoring: Medium- to Long-Term Subjective and Objective Analysis ORIGINAL ARTICLE Laser-Assisted Uvulopalatoplasty for Snoring Medium- to Long-term Subjective and Objective Analysis Gilead Berger, MD; Yehuda Finkelstein, MD; Gideon Stein, MD; Dov Ophir, MD Objective: To assess the subjective and objective me- (11/14) to 57% (8/14) was recorded; furthermore, state dium- to long-term results of laser-assisted uvulopala- of snoring worsened from 7% (1/14) to 21% (3/14). Like- toplasty for snoring. wise, reevaluation of the 5 other sleep-related symp- toms at the final follow-up visit uncovered a 57% im- Design: A nonrandomized, prospective, before-after trial. provement rate. Overall satisfaction with the procedure was 43%. The results of the postoperative objective stud- Subjects and Interventions: Fourteen patients un- ies corresponded to those of the subjective ones and dem- derwent laser-assisted uvulopalatoplasty surgery; 2 sur- onstrated significant worsening of respiratory distur- gical techniques, which differ with respect to the mode bance index in 3 (21%) of the 14 patients, who became of midline palatal vaporization, were used. mildly apneic. These findings were encountered with both laser techniques. Main Outcome Measures: Subjective analysis in- cluded a preoperative and 2 postoperative evaluations of Conclusions: The favorable subjective short-term re- the state of snoring: 4 weeks and 10.1±7.9 months sults of laser-assisted uvulopalatoplasty deteriorated with (mean±SD) after completion of last laser treatment. In time. In addition, postoperative nocturnal polysomnog- addition, a score on 5 other sleep-related symptoms was raphy showed that the procedure caused mild obstruc- recorded before treatment and after 10.1±7.9 months; tive sleep apnea in a considerable number of patients who at that time, patients also estimated their overall satis- formerly were nonapneic snorers. These findings may be faction with the procedure. Objective analysis included related to velopharyngeal narrowing and progressive pala- preoperative nocturnal polysomnographic studies that tal fibrosis, caused by the thermal damage inflicted by were repeated postoperatively. the laser beam. Results: A decline in snoring improvement from 79% Arch Otolaryngol Head Neck Surg. 2001;127:412-417 NORING IS a common phe- city of medium- to long-term data regard- nomenon and may be asso- ing the durability of these favorable re- ciated with restless sleep, sults. Wareing and Mitchell,5 Wareing et night awakening, morning fa- al,6 and Ellis,7 for example, demonstrated tigue, daytime somnolence, that LAUP was associated with a consid- Sand hypoxemia. Snoring, even without ap- erable number of delayed failures. Fur- nea, can be a risk factor for hypertension, thermore, the available reports included angina pectoris, cerebral infarction, pul- subjective data to analyze the effective- monary hypertension, and congestive heart ness of LAUP for snoring, while postop- failure.1,2 This has led to the search for a erative polysomnography (PSG) has been From the Department of compatible solution to a socially vexing regularly excluded. This tendency prob- Otolaryngology–Head and problem and its potentially life-threaten- ably derives from the encouraging re- Neck Surgery (Drs Berger, ing pathologic consequences. sults reported for LAUP and the high cost Stein, and Ophir) and the Laser-assisted uvulopalatoplasty of the sleep studies. Consequently, the sur- Palate Surgery Unit (LAUP) is considered a popular and well- geons evaluated the procedure in terms of (Dr Finkelstein), Meir General received surgical procedure to eliminate whether it eliminated snoring, but lacked Hospital, Sapir Medical Center, Kfar Saba, Israel; and the snoring and to treat obstructive sleep ap- information regarding possible changes in Sackler School of Medicine, nea (OSA). Reports on the efficacy of the the objective sleep parameters. Tel-Aviv University, Tel-Aviv, procedure for snoring were promising, This clinical study forms part of a re- Israel (Drs Berger, Finkelstein, with a clinical success rate ranging from search project conducted on the late ana- Stein, and Ophir). 70% to 95%.3-5 There is, however, a scar- tomic and histopathologic changes of the (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 127, APR 2001 WWW.ARCHOTO.COM 412 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 PATIENTS AND METHODS SURGICAL METHODS Two surgical techniques of LAUP were used, differing with The study population consisted of 14 patients who had both- respect to the mode of midline palatal vaporization. Nine ersome snoring and completed LAUP treatment between patients underwent the first technique (type 1), in which June 1, 1994, and March 30, 1995, at the outpatient clinic a focused continuous beam of 15 to 20 W was used to ex- of Meir General Hospital, Sapir Medical Center, Kfar Saba, cise the uvular base, through the full palatal depth, and then Israel. All patients consented to participate in the study af- extended bilaterally to the anterior and posterior tonsillar ter being informed of the known benefits, risks, and com- pillars. Serial laser tonsillectomy was also performed. It was plications of the procedure. There were 10 men and 4 carried out in 1 to 2 sessions, with a mean of 1.22. women, ranging in age from 40 to 66 years (mean±SD, Five patients underwent the second technique (type 51.2±7.5 years). They were generally healthy, and their 2), in which through-and-through full-thickness vertical mean body mass index (calculated as weight in kilograms trenches were created on the free edge of the soft palate, divided by the square of height in meters) was 26.7±3.7 on either side of the uvula, at a power setting of 15 to 20 (Table 1). W. With the use of a SwiftLase scanner (Sharplan Lasers, Inc, Allendale, NJ) attached to the carbon dioxide laser, as PREOPERATIVE EVALUATION described by Krespi et al,4 the core of the uvula was re- moved from the bottom up, in a “fishmouth” manner, while Patients’ and bed partners’ detailed histories relevant to up- the mucosa of the uvula was preserved. Eventually, the uvula per airway obstruction were obtained in structured inter- was shortened and thinned by up to 80% to 90% of its origi- views. They were requested to describe their snoring state nal size. This technique was carried out in 1 to 2 sessions, and to indicate the absence (0) or existence (1) of 5 other with a mean of 1.4. sleep-related symptoms. The first 3 were addressed to the patients and the remaining 2 to their bed partners and in- POSTOPERATIVE EVALUATION cluded (1) night awakening, (2) morning fatigue, (3) day- time somnolence, (4) episodes of sleep apnea, and (5) in- All patients were reexamined 4 weeks and 3.5 to 36 months voluntary body movements during sleep. A total score from (mean±SD, 10.1±7.9) after completion of the last laser treat- 0 to 5 was calculated for each patient. ment. On both occasions, they were asked to compare snor- All subjects underwent a complete otolaryngologic ex- ing with its preoperative state and to answer whether it (1) amination, including flexible fiberoptic nasopharyngo- was abolished or markedly reduced, (2) remained the same, scopic examination of the nose, pharynx and larynx, and or (3) had worsened. Furthermore, 5 other sleep-related had nocturnal PSG with simultaneous electroencephalog- symptoms were assessed at the end of the follow-up pe- raphy, electrocardiography, electromyography, and surface- riod, and a total score from 0 to 5 (as described earlier) was electrode electro-oculography. Air flow at the nose and calculated for each patient. Possible variations between the mouth was monitored with thermistors, and respiratory ef- preoperative and postoperative score indicated whether fort was assessed with inductive plethysmography. Oxy- patients (1) improved, (2) remained unchanged, or (3) wors- gen saturation was measured with continuous finger pulse ened. They were also asked to estimate their overall satis- oxymetry. The severity of OSA was expressed in terms of faction with the procedure with a yes-no answer. a respiratory disturbance index (RDI), calculated as the av- The PSG was repeated immediately after the last erage number of apneas plus hypopneas per hour of sleep. follow-up visit, at the same sleep laboratory, with the use The study defined patients as (1) snorers when RDI was 0 of previously determined criteria for evaluation. All pa- to 5, (2) mildly obstructed when RDI was 6 to 20, (3) mod- tients were photographed intraorally immediately and 2 erately obstructed when RDI was 21 to 40, and (4) severely weeks and 10.1±7.9 months after last laser treatment. obstructed when RDI was greater than 40. All patients were categorized as nonapneic snorers if they had an RDI of 5 STATISTICAL ANALYSIS or less. Patients were photographed intraorally by means of a 35-mm camera (Yashica FX-3 Super 2000; Yashica, To- Measurements were expressed as mean±SD. Compari- kyo, Japan), mounted with a medical lens (Yashica 100 DX; sons were performed by paired t test and nonparametric Yashica), and adjusted on a fixed reproduction ratio of two Mann-Whitney test. Probability values of P,.05 were con- thirds. sidered significant. soft palate after LAUP8,9 and was undertaken to assess symptoms. During the interval between follow-up vis- the efficacy of the procedure for snoring with regard to its, improvement in snoring declined from 79% (11/ (1) the durability of the subjective results as time 14) to 57% (8/14), and worsening in snoring increased progresses and (2) the postoperative objective out- from 7% (1/14) to 21% (3/14). Analysis of the 5 other come. sleep-related symptoms at the final follow-up showed a similar success rate (57%). One patient had deterio- RESULTS ration of symptoms in this respect. Patients’ overall satisfaction with LAUP, which was also assessed at the SUBJECTIVE ASSESSMENT last follow-up visit, established that only 6 patients (43%) were satisfied, while the remaining 8 (57%) Table 2 compares the changes in snoring state and were dissatisfied and reluctant to go through the pro- the score of each patient in the 5 other sleep-related cedure again.
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