Is There a Better Way to Do Laser-Assisted Uvulopalatoplasty?

ORIGINAL ARTICLE Is There a Better Way to Do Laser-Assisted Uvulopalatoplasty?

Gilead Berger, MD; Gideon Stein, MD; Dov Ophir, MD; Yehuda Finkelstein, MD

Objective: To assess the subjective and objective short- and (PϽ.001). Evaluation of 5 other sleep-related symp- medium- to long-term results of laser-assisted uvulopala- toms showed that 52% of patients (n=13) improved and toplasty (LAUP) for snoring and obstructive sleep apnea. 20% (n=5) worsened. Polysomnography of LAUP patients showed that the mean postoperative respiratory dis- Design: A nonrandomized, prospective, before-after trial. turbance index worsened significantly (33.1±23.1) compared with the preoperative one (25.3±14.3) (P=.05); Patients and Interventions: Twenty-five patients un- also, 20% of the procedures were successful and 36% re- derwent a modified procedure of LAUP termed one- vealed marked worsening. The respiratory disturbance stage LAUP, and a matched control group of 24 patients index of uvulopalatopharyngoplasty patients changed underwent uvulopalatopharyngoplasty. from 26.0±18.0 to 18.7±21.3, yet improvement did not reach statistical significance (P=.09). Furthermore, 58% Main Outcome Measures: Subjective analysis of LAUP (n=14) of the surgical procedures were successful and included a preoperative and 2 postoperative evaluations of only 8% (n=2) revealed marked worsening. thestateofsnoring(4weeksandafteramean±SDof12.2±9.9 months). A score on 5 other sleep-related symptoms was Conclusions: The favorable, subjective, short-term re- recorded before and after completion of LAUP. The objec- sults of modified LAUP deteriorated over time. The pro- tivepolysomnographicoutcomeswerecomparedwithacon- cedure might also lead to aggravation of existing apnea. trol group undergoing uvulopalatopharyngoplasty. These findings are probably related to progressive palatal fibrosis and velopharyngeal narrowing originated by Results: In 25 patients, improvement in the state of snor- the laser beam. ing significantly declined from 76% (n=19) to 32% (n=8), and worsening increased from 12% (n=3) to 32% (n=8) Arch Otolaryngol Head Neck Surg. 2003;129:447-453

ASER-ASSISTED uvulopalato- generation of OSA in formerly nonapneic plasty (LAUP) was initially patients who only snored,9 or lead to de- designed for the manage- terioration of existing sleep apnea.10 ment of snoring1; gradu- Dickson and Mintz11 introduced a ally, it has been extended to modified technique of LAUP, which they treatingL various degrees of obstructive termed one-stage LAUP. This modified sleep apnea (OSA). Laser-assisted uvulo- technique was designed to reduce the over- palatoplasty is an office procedure per- all pain of the patients and the cost of stan- formed with the patient under local anes- dard LAUP. During surgery, a curvilin- thesia and requires several sessions until ear horizontal incision is made under the From the Department of satisfactory results are achieved. During palatal dimple, and ultimately the same Otolaryngology–Head and surgery, which has been extensively de- amount of soft palate tissue is removed as Neck Surgery (Drs Berger, scribed by Krespi et al,2 vertical trenches in UPPP. The authors reported excellent Stein, and Ophir) and the are created on either side of the uvula into short-term subjective results and a suc- Palate Surgery Unit of the the soft palate, coupled with shortening cessful objective response. Seemann et al12 Department of and trimming of the uvula. Several stud- also used one-stage LAUP and reported en- Otolaryngology–Head and ies3-7 have examined the efficacy of the couraging results. Ryan and Love,13 on the Neck Surgery (Dr Finkelstein), technique, recognized as standard LAUP, other hand, concluded that the response Meir Hospital, Sapir Medical Center, Kfar Saba, and Sackler and reported comparable results to uvu- to this technique was varied and unpre- Faculty of Medicine, Tel-Aviv lopalatopharyngoplasty (UPPP). How- dictable, and only a few patients achieved University, Tel-Aviv, Israel. ever, other studies found that LAUP was a satisfactory outcome. The authors have no relevant ineffective,8 had deleterious effects on the In view of the discrepancy, the pres- financial interest in this article. respiratory dynamics and may trigger the ent study, which forms part of a research

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 project on the late anatomic,14 histopathologic,15 and clini- cal anesthesia included 1.5% lidocaine spray applied to the oro- cal results of LAUP,9,10 evaluates the short- and me- pharynx and the oral cavity, followed by local infiltration of a dium- to long-term subjective and objective results of the mixture of 1% lidocaine and 0.01% adrenaline into either side of the base of the uvula and at the upper edges of the anterior one-stage LAUP procedure for patients with OSA. Spe- 11 cial emphasis was placed on the durability of the sub- tonsillar pillars. Similar to the Dickson and Mintz method, the carbon dioxide laser (Sharplan Lasers Inc, Allendale, NJ) jective results over time and the postoperative objective was used in a focused continuous mode at 15 to 20 W to ex- outcome of the treatment. cise the uvular base below the dimple through the full palatal depth, while the levator muscles remained intact. The exci- METHODS sion was extended bilaterally to the anterior and posterior tonsillar pillars, leaving the same amount of tissue at the end of The study population consisted of 25 patients with bothersome surgery as in UPPP. To achieve a satisfactory outcome, in sev- snoring and various degrees of OSA who had completed LAUP eral cases treatment was repeated. treatment between June 1, 1994, and March 31, 1995, at the outpatient clinic of Meir Hospital, Sapir Medical Center, Kfar Saba, POSTOPERATIVE EVALUATION Israel. All patients were generally healthy, without a cleft lip or palate; none had undergone prior mandibular or maxillary sur- All patients were reexamined 4 weeks and 5 to 48 months gery. They consented to participate in the study and undergo treat- (mean±SD, 12.2±9.9 months) after completion of laser treatment after being informed of the known benefits, risks, alterna- ment. On both occasions, they were asked to compare current tives, and complications of the procedure. Inclusion in the study snoring with its preoperative state and to answer whether it was was contingent on completion of all diagnostic studies. abolished or markedly reduced, remained the same, or had worsened. In addition, the 5 other sleep-related symptoms were as- PREOPERATIVE EVALUATION sessed at the end of the follow-up period, and a total score from 0 to 5 was calculated for each patient. Possible variations be- Patients’ detailed histories and bed partners’ reports relevant tween the preoperative and postoperative score indicated whether to upper airway obstruction were obtained in structured inter- patients improved, remained unchanged, or worsened. Patients views. As previously reported,9,10 interviewees were asked to were also asked to estimate their overall satisfaction with the pro- describe their state of snoring and to indicate the absence (0) cedure with a yes or no answer. Polysomnography was repeated or existence (1) of the following 5 other sleep-related symp- shortly before the follow-up visit, at the same sleep laboratory, toms: night awakening, morning fatigue, daytime somno- with the use of previously determined criteria for evaluation. In lence, breathing pauses, and involuntary body movements dur- addition, patients were photographed intraorally on 3 occa- ing sleep. Questions on the first 3 symptoms were addressed sions: immediately after treatment, 4 weeks after treatment, and to the patients and the remainder to their bed partners. A total at the final follow-up period (mean±SD, 12.2±9.9 months), with score from 0 to 5 was calculated for each patient. the use of the previously described camera. All patients underwent a complete otolaryngologic examination, including flexible fiberoptic nasopharyngoscopic exami- CONTROL GROUP nation of the nose, pharynx, and larynx, and nocturnal polysomnography with simultaneous electroencephalography, A matched control group of patients who underwent UPPP pro- electrocardiography, electromyography, and surface-electrode vided a basis for comparison of the objective finding of LAUP. electro-oculography. Airflow at the nose and mouth was moni- The control group consisted of 24 patients who experienced tored with thermistors, and respiratory effort was assessed with bothersome snoring and various degrees of OSA and under- inductive plethysmography. Oxygen saturation was measured with went a complete otolaryngologic examination, including flex- continuous finger pulse oxymetry. Severity of OSA was ex- ible fiberoptic nasopharyngoscopic examination of the nose, pressed in terms of a respiratory disturbance index (RDI) and cal- pharynx, and larynx and nocturnal polysomnography. Surgi- culated as the average number of apneas plus hypopneas per hour cal procedures were completed between February 1, 1993, and of sleep. The study defined patients as (1) nonapneic snorers when November 30, 1999, at the Meir Hospital, Sapir Medical RDI was 0 to 5, (2) mildly obstructed when RDI was 6 to 20, (3) Center, Kfar Saba, Israel. Similar criteria for inclusion de- moderately obstructed when RDI was 21 to 40, and (4) severely scribed previously were applied. The procedure was discussed obstructed when RDI was greater than 40. Maximal snoring in- in the process of informed consent. tensity was measured with a microphone located above the pa- Uvulopalatopharyngoplasty was performed with the patient’s head at a distance of 1 m and connected to a sound level tient under general endotracheal anesthesia. Following tonsil- meter (model 2700; Quest Electronics, Oconomowoc, Wis). The lotomy, the soft palate was resected just below the palatal dimple, output from the sound level meter was parallel recorded on a cali- thus avoiding injury to the levator veli palatini muscle sling. brated chart (40 to 80 dB) recorder at a paper speed of 10 cm/h. The incisions were then arched laterally through the full thick- It should be indicated that a low preoperative RDI and normal ness of the tonsillar pillars. Careful suturing of the free edges saturations were treated only when maximal snoring intensity dis- of the anterior and posterior pillars completed surgery. Fol- rupted sleep and affected marital harmony and patients’ state of low-up lasted 2 to 49 months (mean±SD, 9±10.5 months) af- health. Furthermore, patients were photographed intraorally to ter completion of surgery; shortly before that time polysom- establish a reference point for comparison with the postopera- nography was repeated at the same sleep laboratory where all tive oropharyngeal appearance. Photographs were taken with a the other studies were performed. 35-mm camera (FX-3 Super 2000; Yashica, Tokyo, Japan), mounted with a medical lens (Yashica 100 DX; Yashica), and ad- DEFINITION OF TREATMENT EFFECTIVENESS justed on a fixed reproduction ratio of two thirds. Evaluation was based on commonly accepted definitions found SURGICAL METHOD in the literature.5,13,16 Surgery was considered successful when patients had at least a 50% reduction of their postoperative RDI The modified LAUP procedure was performed in the office set- compared with the preoperative value or when it dropped be- ting while the patient was in an upright sitting position. Topi- low 20 events per hour (an RDI above which OSA may be as-

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RDI LSAT, %

Patient No. Follow-up, mo Preoperative Postoperative Preoperative Postoperative 11013159490 2 7 20 13 90 91 3 5 32 12 90 92 4 5 28 58 80 71 51422278689 6 5 26 33 90 89 71225428175 8 7 73 86 77 81 9 8 18 36 92 91 10 6 11 17 91 94 11 6 8 73 84 82 12 10 28 7 84 90 13 5 39 68 72 56 14 10 30 34 90 81 15 7 20 38 86 90 16 18 25 20 91 75 17 5 26 21 88 87 18 12 38 47 NA 91 19 24 19 19 100 92 20 22 20 4 86 91 21 24 28 46 95 89 22 6 13 8 90 86 23 24 52 63 90 74 24 5 8 0 83 99 25 48 12 42 92 83 Mean ± SD 12.2 ± 9.9 25.3 ± 14.3 33.1 ± 23.1 87.6 ± 6.1 84.9 ± 9.4

Abbreviations: LSAT, lowest oxygen saturation; NA, not applicable; RDI, respiratory disturbance index.

sociated with significantly increased morbidity and mortality). (3/25) to 32% (8/25). Three patients (12%) had no change Surgery was considered unsuccessful when postoperative RDI in snoring at the first follow-up visit and 9 (36%) had was reduced by less than 50% from preoperative value, post- no change at the last follow-up visit. Statistical analysis operative RDI remained unchanged, or postoperative RDI val- confirmed that the deterioration in the state of snoring ues worsened. during the time lapse between the follow-up visits was Ͻ STATISTICAL ANALYSIS statistically significant (P .001). Examination of the 5 other sleep-related symptoms at the final follow-up visit Comparisons were made by the paired t test and the McNemar revealed that only 13 (52%) of 25 patients had improve- test. Measurements are expressed as mean±SD; PϽ.05 is con- ment of symptoms, whereas 5 (20%) of 25 reported ag- sidered statistically significant. gravation of symptoms. Seven patients (28%) experienced no change in symptoms. An assessment of patients’ RESULTS overall satisfaction from LAUP, which was also performed at the last follow-up visit, established that 9 pa- Twenty-two men and 3 women, ranging in age from 32 tients (36%) were satisfied, whereas the remaining 16 to 71 years (49.6±9.8 years), underwent LAUP treat- (64%) were dissatisfied and reluctant to undergo the pro- ment. Their preoperative mean body mass index (BMI), cedure again. calculated as weight in kilograms divided by the square of height in meters, was 27.5±3.2. Assessment at the end OBJECTIVE OUTCOMES of the follow-up period revealed no significant change OF LAUP (27.5±3.6) of the BMI levels (P=.86). The preoperative maximal snoring intensity for the whole group was Table 1 shows the objective findings recorded before 64.6±5.0 dB. Eighteen (72%) of the 25 LAUP patients treatment and at the conclusion of the follow-up. A com- underwent 1 treatment, 5 (20%) needed 2 treatments, and parison between the mean preoperative and postopera- 2 (8%) needed 3 (mean treatments, 1.4±0.6 treatments). tive RDI values of the whole group revealed a signifi- The interval between sessions was approximately 6 weeks. cant worsening in this respect (25.3±14.3 vs 33.1±23.1, respectively) (P=.05). Figure 1 demonstrates that only SUBJECTIVE OUTCOMES OF LAUP 5 patients (20%) had a successful surgery, whereas 3 (12%) had insufficient success (ie, reduction of RDI During the interval between follow-up visits, improve- levels by less than 50% from preoperative value). Two ment in snoring declined from 76% (19/25) to 32% patients (8%) had no change in the preoperative RDI. (8/25), and worsening in snoring increased from 12% Furthermore, 15 patients (60%) had a worsening of

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40 n = 9

30 Percentage n = 6 n = 5 n = 5 20 n = 3 n = 3 10 n = 2 n = 2

0 Success Insufficient No Moderate Marked Success Change Worsening Worsening B

Figure 1. The effectiveness of one-stage laser-assisted uvulopalatoplasty (LAUP) and uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA) treatment. Success is indicated by at least a 50% reduction of postoperative respiratory disturbance index (RDI) value or an RDI with fewer than 20 events per hour; insufficient success, a less than 50% reduction of postoperative RDI value; no change, unchanged postoperative RDI values; moderate worsening, worsening of postoperative RDI values without a change of sleep apnea status; and marked worsening, worsening of postoperative RDI values with a change of sleep apnea status (from mild to moderate OSA, from mild to severe OSA, or from moderate to severe OSA).

postoperative RDI, 6 (24%) of whom had a moderate C worsening of RDI values that was not associated with a change of sleep apnea status, and 9 (36%) had a marked worsening of postoperative RDI values that was associated with a change of sleep apnea status from mild to moderate OSA (patients 9 and 15), from mild to severe OSA (patients 11 and 25), and from moderate to severe OSA (patients 4, 7, 13, 18, and 21). In 3 patients (4, 11, and 25), RDI worsening was greater than 100% from the preoperative value. Preoperative and postoperative mean lowest oxygen saturation levels were not significantly dif- ferent (87.6%±6.1% vs 84.9%±9.4%, respectively) (P=.11). Nevertheless, patient 13 had a change of preoperative lowest oxygen saturation from 72% to 56%, a D deleterious lowering consistent with the shift from moderate to severe OSA (Table 1). Intraoral photographs (Figure 2) demonstrate that the size of the oropharyngeal isthmus, which underwent a substantial enlargement shortly after surgery (Figure 2B and C), was reduced at the end of the follow-up period (Figure 2D). This reduction is related to a curtainlike medial traction of the posterior pillars and to a pulling of the lateral pharyngeal walls medially.

COMPLICATIONS AND ADVERSE Figure 2. Preoperative and postoperative intraoral photographs of a patient EFFECTS OF LAUP who underwent one-stage laser-assisted uvulopalatoplasty. A, Preoperative view; B, immediate postoperative view; C, 4-week postoperative view; and There were no life-threatening complications, includ- D, late postoperative view. Note the medial curtainlike traction of the posterior pillars (white arrows, D). ing postoperative airway obstruction or hemorrhage. The most common adverse effect of LAUP was pain, which lasted from 5 to 21 days postoperatively (mean±SD du- OBJECTIVE OUTCOMES OF UPPP ration, 9.7±3.8 days) and was severe enough to keep patients away from work for 7±2.6 days. At the end of the A control group of 22 men and 2 women, ranging in age follow-up visit, 12 patients (48%) complained of persis- from 28 to 69 years (48.8±11.1 years), underwent UPPP. tent throat dryness or itching. One patient developed ve- The preoperative BMI was 28.3±3.2. Assessment at the lopharyngeal stenosis and underwent corrective sur- end of the follow-up period revealed no significant change gery to relieve obstruction. of the BMI levels (28.6±3.1) (P=.34). The preoperative

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RDI LSAT, %

Patient No. Follow-up, mo Preoperative Postoperative Preoperative Postoperative 1 8 11 14 92 93 2 7 9197890 3 3 76 94 67 72 4 5 8149491 5 7 10 25 82 88 6 5 14 10 96 92 7 5 26 21 88 87 8 14 42 3 59 78 9 7 20 10 82 86 10 5 53 7 60 86 11 4 25 2 86 92 12 7 16 7 84 84 13 8 17 9 94 93 149 36207680 15 2 17 6 91 91 16 3 26 4 83 93 17 5 17 4 85 88 184 54276277 19 30 20 27 88 91 203 32147591 21 4 23 5 64 73 224 55418985 23 19 11 4 90 90 24497639098 Mean ± SD 9.0 ± 10.5 26.0 ± 18.0 18.7 ± 21.3 81.5 ± 11.4 87.0 ± 6.7

Abbreviations: LSAT, lowest oxygen saturation; RDI, respiratory disturbance index.

maximal snoring intensity for the whole group was aggravation of the state of snoring after 12.2±9.9 65.6±9.1 dB. Table 2 presents the objective findings re- months. Assessment of 5 other sleep-related symptoms corded before treatment and at the conclusion of the fol- at the end of the follow-up revealed a low success rate low-up. A comparison between the mean preoperative (52%, 13/25) and a 20% failure rate (5/25) that and postoperative RDI values of the whole group re- accorded with the poor results found earlier. Wareing vealed an improvement in this respect, yet it did not reach and Mitchell17 and Wareing et al18 also pointed out that statistical significance (26.0±18.0 vs 18.7±21.3, respec- LAUP was associated with delayed failures in a sizable tively) (P=.09). Fourteen patients (58%) had a success- number of patients, with reappearance of socially dis- ful surgery, whereas 3 (13%) had insufficient success (Fig- ruptive snoring in one fifth of the patients who earlier ure 1). Seven patients (29%) had a worsening of had benefited from the procedure. postoperative RDI, 5 (21%) of whom had a moderate The late objective findings of one-stage LAUP were worsening of RDI values, whereas the remaining 2 (8%) disappointing and in keeping with the subjective ones. had a significant worsening of postoperative RDI values Statistical analysis confirmed that the mean postopera- associated with a change of sleep apnea status from mild tive RDI values were significantly higher than the pre- to moderate OSA (patient 5) and from mild to severe OSA operative ones (P=.05), indicating a genuine worsening (patient 24). In patients 2 and 24, RDI worsening was in this respect. Evaluation of surgery disclosed that only greater than 100% from the preoperative value. Postop- 5 (20%) of the 25 patients had a successful surgery, erative mean lowest oxygen saturation levels improved whereas 15 (60%) had either moderate or marked wors- significantly (81.5%±11.4% vs 87.0%±6.7%, respec- ening of RDI values. Ryan and Love13 obtained a good tively) (P=.002) (Table 2). response in only 27% of the patients, a partial response in 9%, a poor response in 34%, and worsening in 30%. COMMENT Our data substantially differ from those of Dickson and Mintz,11 who reported a 75% to 100% improvement Nineteen (76%) of 25 patients who underwent one- in snoring by 83% of the patients. Only 14 patients un- stage LAUP to treat symptoms of snoring and OSA derwent preoperative and postoperative polysomnogra- experienced an initial subjective improvement of the phy, 10 (71%) of whom responded successfully to LAUP. state of snoring. Comparable findings were recorded in Seemann et al12 recently found a significant objective im- nonapneic patients who snored (79%, 11/14)9 irrespec- provement in 60% of the patients by apnea index crite- tive of the type of laser surgery and in apneic patients rion and a 32% improvement by RDI criterion, after an (88%, 23/26) who underwent standard LAUP.10 How- average follow-up of 9.4 weeks, and concluded that LAUP ever, similar to the latter, there was a significant dete- is an effective and safe treatment for sleep-disordered rioration of the early favorable results and a significant breathing. Evidently, methodologic dissimilarities re-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 garding the length of the follow-up period exist among ous lubrication to the oropharynx and probably to the the studies. Although our mean follow-up period lasted vocal cords.25 Of special note is the development of se- for more than 12 months, in the Dickson and Mintz vere scarring, resulting in velopharyngeal stenosis in 1 study11 it was approximately 3 to 4 months for the sub- patient. Huet et al26 and Carenfelt24 also found that in 3 jective symptoms and not recorded for the objective ones; patients (12%) and 2 patients (1%), respectively, LAUP in the study by Seemann et al,12 the follow-up period was was associated with scar fibrosis and narrowing of the much shorter. In fact, the findings of both studies re- nasopharyngeal aperture. semble our initial results and significantly differ from the Dickson and Mintz11 disclosed that one-stage LAUP medium- to long-term ones. produces a postoperative picture indistinguishable from In the current study, a focused, continuous beam that of UPPP and that the technique combines the ad- at a power setting of 15 to 20 W was used to vaporize vantages of UPPP, removing a significant amount of tis- the soft palatal tissues. The literature reveals that Ka- sue, and a greatly reduced morbidity seen with standard mami,3 the originator of LAUP; Dickson and Mintz,11 who LAUP. Nevertheless, a comparison between patients who developed the one-stage LAUP; and multiple other re- underwent one-stage LAUP and a control group under- searchers have used comparable wattages.2,4,6,19,20 Troell going UPPP by the same surgeons and matched by sex, et al21 even used a higher power setting of 18 to 24 W. age, preoperative BMI and RDI levels, preoperative maxi- On the other hand, Lauretano et al8 and Pribitkin et al22 mal snoring intensity, and duration of follow-up period operated at a lower power (14 to 18 W and 10 W, emphasizes appreciable differences. Although only 5 respectively). (20%) of the 25 modified laser procedures were success- Similar to standard LAUP, intraoral photographs ful, an approximate 3-fold increase in the success rate demonstrated a substantial enlargement of the oropha- (14/24, 58%) was found in UPPP procedures. The latter ryngeal isthmus immediately after surgery, causing tem- is compatible with other reports.16 Furthermore, a greater porary relief of signs and symptoms in a considerable num- proportion of the patients exhibited marked worsening ber of patients. However, with the passage of time there of RDI levels (9/25, 36%) after modified laser procedure was a late decline in the improvement of snoring, aggra- than after UPPP (2/24, 8%) (Figure 1). Thus, the study vation of the sleep-related symptoms, and an overall fail- shows that UPPP is a more effective and a far less mor- ure in the objective measures. These results are attrib- bid procedure than one-stage LAUP. Moreover, the study utable to the progressive fibrosis inflicted on soft palate posed the question of whether there is a better way to tissues by the thermal damage of the laser beam, which do LAUP. Based on the medium- to long-term current leaves a raw surface that subsequently undergoes scar- experience and that of standard LAUP, it can be con- ring. These wounds take longer to heal than those cre- cluded that both procedures were disappointing, yet the ated with a scalpel.23 The effectiveness of surgery, there- former was inferior to standard LAUP in every aspect.10 fore, should be assessed months later, when the healing For example, improvement in the state of snoring was process has stabilized. Indeed, a study on the long-term 32% (8/25) compared with 65% (17/26), and the overall histopathologic changes after LAUP disclosed that the vari- satisfaction from LAUP was 36% (9/25) compared with ous components of the soft palate underwent extensive 58% (15/26). Also, there was a significant worsening of changes, with replacement of the loose connective tis- the mean postoperative RDI compared with the preop- sue in the lamina propria by diffuse fibrosis that also ex- erative one (33.1±23.1 vs 25.3±14.3, respectively) tended to the central layer, on the expanse of seromu- (P=.05). However, in standard LAUP the mean postop- cous glands and muscle fibers.15 Palatal fibrosis after LAUP erative RDI improved (25.0±18.8 vs 29.6±21.6, respec- was also encountered in 27% of the patients in the study tively), although this result was not statistically signifi- by Carenfelt.24 It was shown that the pharyngeal scar con- cant (P=.12). Notably, both procedures were performed tracture occurred in the centripetal direction and caused in the same office setting and by the same surgeons; also, a curtainlike medial traction of the posterior tonsillar pil- the findings were analyzed with similar criteria for evalu- lars and a pulling of the lateral pharyngeal walls medi- ation. The differences among the studies probably ally. Eventually, the pharyngeal cross-sectional area went derive from a greater narrowing of the velopharyngeal through major anatomic changes that included narrow- isthmus that occurred after one-stage LAUP. The mea- ing of the lumen, increased rigidity, decreased compli- surements of Finkelstein et al,14 which have shown a sig- ance, and loss of distensibility needed during inspira- nificantly greater distance between the tonsillar pillars tion.14 These deficiencies have deleterious effects on the after standard LAUP compared with the modified pro- respiratory dynamics and may deteriorate existing OSA. cedure and after UPPP compared with the 2 LAUP tech- The most common adverse effect was pain, which niques, support this contingency. lasted up to 21 days postoperatively (9.7±3.8 days); an almost identical finding has been found in standard CONCLUSIONS LAUP.10 Troell et al21 showed a mean of 13.8 days with pain. The procedure was also associated with annoying Laser-assisted uvulopalatoplasty has gained much popu- pharyngeal dryness and discomfort in 12 patients (48%). larity in the last decade as a cure for OSA, a common yet Other researchers also noted excessive dryness of the potentially life-threatening syndrome. It is commonly ac- mouth and discomfort in the throat after LAUP.9,10,13 The cepted that the subjective, short-term outcome of LAUP reasons for the sensation of dryness is the destruction of is successful; however, the procedure has shown an in- multiple seromucous glands in the uvula and the poste- clination to aggravate patients’ pretreatment condition rior portion of the soft palate, which provide continu- in the medium to long term. In the present series, we

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 found a significant worsening of the mean postopera- 7. Walker RP, Grigg-Damberger MM, Gopalsami C. Laser-assisted uvulopalato- tive RDI, a surgical success in only one fifth of the pa- plasty for the treatment of mild, moderate, and severe obstructive sleep apnea. Laryngoscope. 1999;109:79-85. tients (20%, 5/25), and a marked worsening of postop- 8. Lauretano AM, Khosla RK, Richardson G, et al. Efficacy of laser-assisted uvulo- erative RDI values in 9 (36%), in addition to a late palatoplasty. Laser Surg Med. 1997;21:109-116. worsening of the subjective initial results. Furthermore, 9. Berger G, Finkelstein Y, Stein G, Ophir D. Laser-assisted uvulopalatoplasty for one-stage LAUP has proved inferior to UPPP and stan- snoring: medium- to long-term subjective and objective analysis. Arch Otolaryn- dard LAUP. gol Head Neck Surg. 2001;127:412-417. 27 10. Finkelstein Y, Stein G, Ophir D, Berger R, Berger G. Laser-assisted uvulopalato- An American Sleep Disorders Association Report plasty for the management of obstructive sleep apnea: myths and facts. Arch published in 1994 withheld recommendation of LAUP Otolaryngol Head Neck Surg. 2002;128:429-434. as a suitable surgery to treat OSA, declaring it an experi- 11. Dickson RI, Mintz DR. One-stage laser-assisted uvulopalatoplasty. J Otolaryn- mental procedure because of insufficient data. An up- gol. 1996;25:155-161. date for 2000 issued by the Board of Directors of the 12. Seemann RP, DiToppa JC, Holm MA, Hanson J. Does laser-assisted uvulopalatoplasty work? an objective analysis using pre- and postoperative polysomno- American Academy of Sleep Medicine stated that LAUP graphic studies. J Otolaryngol. 2001;30:212-215. is not recommended for the treatment of sleep-related 13. Ryan CF, Love LL. Unpredictable results of laser-assisted uvulopalatoplasty in breathing disorders, including OSA.28 No specification the treatment of obstructive sleep apnea. Thorax. 2000;55:399-404. has been given as to the type of LAUP technique being 14. Finkelstein Y, Shapiro-Feinberg M, Stein G, Ophir D. Uvulopalatopharyngo- evaluated. The facts and the recommendations pre- plasty versus laser-assisted uvulopalatoplasty: anatomic considerations. Arch Otolaryngol Head Neck Surg. 1997;123:265-276. sented herein are cause for concern and should be con- 15. Berger G, Finkelstein Y, Ophir D. Histopathologic changes of the soft palate fol- sidered before practicing LAUP for the treatment of OSA. lowing laser-assisted uvulopalatoplasty. Arch Otolaryngol Head Neck Surg. 1999; 125:786-790. Accepted for publication September 5, 2002. 16. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of We thank Ilana Gelernter, MA, the Statistical Labo- the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996; 19:156-177. ratory of the School of Mathematics, Tel-Aviv University, 17. Wareing M, Mitchell D. Laser assisted uvulopalatoplasty: an assessment of a tech- for providing statistical consulting, and Rachel Berger, BA, nique. J Laryngol Otol. 1996;110:232-236. for providing writing and editing assistance. 18. Wareing MJ, Callanan VP, Mitchell DB. Laser assisted uvulopalatoplasty: six and Corresponding author and reprints: Gilead Berger, MD, eighteen month results. J Laryngol Otol. 1998;112:639-641. Department of Otolaryngology–Head and Neck Surgery, Meir 19. Gnuechtel MM, Keyser JS, Greinwald JH Jr, Postma GN. Electrocautery versus carbon dioxide laser for uvulopalatoplasty in the treatment of snoring. Laryngo- Hospital, Sapir Medical Center, Kfar Saba, Israel 44281 (e- scope. 1997;107:848-854. mail: [email protected]). 20. Rollheim J, Miljeteig H, Osnes T. Body mass index less than 28 kg/m2 is a predictor of subjective improvement after laser-assisted uvulopalatoplasty for snoring. Laryngoscope. 1999;109:411-414. REFERENCES 21. Troell RJ, Powell NB, Riley RW, Li KK, Guilleminault C. Comparison of postoperative pain between laser-assisted uvulopalatoplasty, uvulopalatopharyngoplasty, and

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