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 pa- tients showed that the mean postoperative respiratory dis- Design: A nonrandomized, prospective, before-after trial. turbance index worsened significantly (33.1±23.1) com- pared 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 pala- tal 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 Ltreating 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 (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 129, APR 2003 WWW.ARCHOTO.COM 447 ©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 ton- sillar 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 out- patient 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 treat- ment 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 wors- ened. 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 exami- nation, including flexible fiberoptic nasopharyngoscopic exami- CONTROL GROUP nation of the nose, pharynx, and larynx, and nocturnal polysom- nography 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 pa- tient’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.