HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Palatal Procedures for Obstructive Sleep Apnea

thought to occur when the posterior tonsillar pillars have been resected and there is tissue contracture. The goal of the z-plasty is to increase the space between the palate and the postpharyngeal wall and between the palate and tongue base. This technique is thought to change the scar contracture tension line to an anterolateral direction and widens the anteroposterior and lateral oropharyngeal airway at the level of the palate. Twenty-five patients treated with Z-palatoplasty (ZPP) were matched with 25 pa- tients treated with classic UPPP. All patients in both groups were treated with radio- frequency tongue base reduction (TBRF), due to unfavorable FTP. Perioperative complications were rare in both groups. Temporary velopharyngeal insufficiency (VPI) was reported in the 12 ZPP and 7 UPPP patients. In all patients the VPI completely resolved by 3 months after surgery. No cases of permanent VPI were encountered in either group. Objective measures of surgical success were AHI and the minimum recorded arterial oxygen saturation as recorded with polysomnography. Using a 50% or greater reduc- tion in postoperative AHI and an AHI less than 20 the ZPP with TBRF resulted in a 68% success where the traditional UPP combined with TBRF had a 28% success rate. The procedure is performed under general anesthesia. Two adjacent flaps are out- lined on the palate. The mucosa of the anterior aspect of the two flaps is removed. The palatal segment splits the uvula and the inferior one-third to one-half of the soft palate in half. A 2-layer closure bringing the midline superior to the margin of the soft palate is performed. The lateral flaps are sewn laterally to the defect ( Fig. 7 ). Radiofrequency volumetric tissue reduction (RVTR) for treatment of sleep-disordered breathing (SDB) was described by Powell and colleagues 22 in 1998. Radiofrequency ablation of soft tissue was used in the palate. This prospective, nonrandomized study of 22 healthy patients with mild SDB (AHI <15) and excessive daytime sleepiness re- ported improvements in sleep efficiency index ( P 5 .002), subjective snoring scores (decrease by 77%), and mean Epworth sleepiness scores (8.5 4.4–5.2 3.3, P 5 .0001). A subsequent prospective, nonrandomized study on 30 patients compared RVTR with LAUP for treatment of snoring. Patients with simple snoring or mild sleep apnea were included. Both treatments were effective in eliminating snoring, but the RVTR was better tolerated. 23 A prospective clinical trial compared RVTR andUPPP in 79 consecutive patients. Pre- operatively, the two groups had no difference of subjective symptoms, age, and BMI. The snoring scores improved significantly in both groups ( P <.001). AHI showed signifi- cant improvement postoperatively in the UPPP group ( P 5 .025) but not after RVTR. 24 During this outpatient procedure in the clinic, the patients had topical application of lidocaine spray to the soft palate. The soft palate was then infiltrated with 2 to 3 mL of 2% lidocaine with 1:100,000 epinephrine in the midline and an additional 1.0 to 1.5 mL lateral to midline on each side. A bipolar radiofrequency electrode was placed in the submucosal layer of the soft palate in 3 different sites: the first in the midline vertically, then paramedian left, and right in a diagonal medial to lateral direction. Up to 3 treat- ments can be performed with a 6-week period of healing between treatments. Post- operative pain was managed with oral pain medication ( Fig. 8 ). RADIOFREQUENCY VOLUMETRIC TISSUE REDUCTION

PILLAR PALATAL IMPLANTS

Pillar palatal implants, or polyethylene terephthalate implants, when inserted in the soft palate cause an inflammatory reaction that leads to the formation of a fibrous

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