HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Palatal Procedures for Obstructive Sleep Apnea

retraction and reduction in circumferential space at the level of the palate. This result could have been secondary to technique or excessive heat causing collateral damage to adjacent tissue. Much of LAUP’s appeal was its ability to be performed on an outpatient basis with topical and local anesthetic. It was described as cost-effective because it avoided the cost of the operating room and subsequent hospitalization. The expense of a laser, however, was cost prohibitive for many practitioners. Cautery-assisted palatal stiffening operation (CAPSO) was an outpatient procedure used for snoring and sleep apnea. Of 25 consecutive patients with obstructive sleep apnea who underwent CAPSO, responders were defined as patients with a 50% or more reduction and less than 10 AHI. With these strict criteria, 40% of patients demon- strated success. 16 For treatment of habitual snoring, 206 patients were treated; a suc- cess rate of 92% was found initially, which decreased to 77% after a year. 17 The procedure was performed with topical anesthetic applied and then 5 mL of 2% lidocaine with 1:100,000 epinephrine injected into the midline soft palate. A blended cautery with needle tip was used to outline an inverted U on the soft palate. A 2-cm piece of mucosa was removed in a superior to inferior direction. The denuded tissue was cauterized to further stiffen the tissue and for hemostasis. The wound was allowed to heal by secondary intention ( Fig. 4 ). Many surgeons had noted that the traditional UPPP may fail because of lateral pharyn- geal wall collapse. Cahali described lateral pharyngoplasty, a new surgical technique designed to splint lateral pharyngeal wall collapse. 18 In a prospective, randomized study, 27 patients were randomly assigned to UPPP or lateral pharyngoplasty. 19 Lateral pharyngoplasty showed a greater decrease in the AHI than in the UPPP group ( P 5 .05). The procedure was performed under general anesthesia with a McIvor mouth gag in place to give adequate exposure. A tonsillectomy was performed or the tonsillar fossa mucosa was removed to identify the palatoglossus and palatopharyngeus muscles. With the use of a microscope, the superior pharyngeal constrictor (SPC) muscle was undermined and elevated. The SPC muscle was sectioned caudally resulting in muscle flaps that were sutured anteriorly to the same-side palatoglossus muscle ( Fig. 5 ). An incision was made from the lateral base of the uvula extending diagonally laterally of the upper part of the palatopharyngeus muscle, which created a palatine laterally based flap. A transverse subtotal section of the palatopharyngeus muscle was made in its superior part creating a superior and an inferior flap. The superior and palatine flaps were sutured in a z-plasty fashion. The anterior to the posterior tonsillar pillars were sutured. Then the distal third of the uvula was removed. Expansion sphincter pharyngoplasty (ESP) was described by Pang and Woodson 20 to prevent lateral wall collapse in patients with obstructive sleep apnea. 20 In a prospec- tive, randomized controlled trial, 45 adults with a BMI less than 30, Friedman stage II or III, and with lateral wall collapse had either traditional UPPP or the ESP. Using a sur- gical success definition of a 50% reduction and less than 20 AHI, ESP had 82.6% suc- cess compared with 68.1% in UPPP ( P <.05). CAUTERY-ASSISTED PALATAL STIFFENING OPERATION LATERAL PHARYNGOPLASTY EXPANSION SPHINCTER PHARYNGOPLASTY

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