Chapter 61 Salvage of failed palate procedures for sleep-disordered breathing
Surgical procedures designed to shorten or otherwise modify the palate may provide relief of upper airway collapse at the palatal level in patients with sleep disordered breathing (SDB). For patients who fail, or suffer a relapse after an initial surgical success, salvage surgical techniques may be appropriate. Although the principles of these salvage techniques are similar to the commonly performed primary surgical procedures, subtle modifications of the approach are sometimes required, and these are emphasized in this chapter.
The uvulopalatopharyngoplasty (UPPP) procedure has become a mainstay in the management of palatal collapse for patients with SDB. A review of literature has shown that 40.7% of patients who have undergone this procedure have a favorable response. A favorable response is defined as either an Apnea/Hypopnea Index (AHI) of less than 10 episodes per hour or an AHI <20 per hour as well as a 50% decrease in the AHI from the base line.1 In addition, in an effort to decrease the morbidity of surgical treatment, several office-based surgical interventions have been developed and implemented for the treatment of obstruction at the palate level, including laser-assisted uvulopalatoplasty (LAUP), and radiofrequency ablation of the palate (RFAP). While these procedures have proven effective in treating mild SDB in short-term analyses, the long-term evaluation of these procedures has revealed a substantial rate of recurrence of both the snoring and daytime sleepiness, and in some cases a steady trend toward recurrence has been shown over time.2 In patients with severe sleep apnea, however, it was demonstrated that UPPP has virtually no place in its management.
The salvage of patients who have undergone these procedures and either failed at the palate or suffered long-term recurrence of symptoms has received relatively little attention in medical literature. Re-treatment has been considered, and reports of successful series of patients have been documented. Li et al. showed that patients who have relapsed after successful RFAP treatment may be rescued with subsequent RFAP procedures with improvement in both snoring and sleepiness. The potential for long-term recidivism following UPPP, LAUP and RFAP procedures with a second palate procedure, emphasizes the need for technical knowledge in surgically managing patients who have failed initial palate surgery for SDB. We describe the implementation of well-known palatal intervention in patients who have been previously treated with a palatal procedure. We have found that many of these patients who have either failed initial treatment with prior palatal surgery or suffered a long-term recurrence may be successfully salvaged.
We consider here the use of four basic palatal surgical interventions: UPPP, LAUP, RFAP and palatal advancement, while recognizing that there are a number of other effective treatments. Although all these procedures are designed to enlarge the velopharyngeal isthmus and to decrease the vibration of the soft palate, they achieve this goal in different ways. We acknowledge that virtually any permutation of primary procedure and secondary salvage procedure can be considered. To illustrate the essential possibilities, however, we have focused on five typical circumstances that lend themselves, primarily because of the post-surgical anatomy, to one or other of the salvage strategies.
Patients who have had their snoring successfully mitigated with LAUP but have experienced a relapse may be appropriate candidates for re-treatment with LAUP. If they are reluctant to suffer the discomfort associated with this procedure, or if they are experiencing any type of dysphagia symptoms or occasional aspiration as a result of the prior treatment, it may be preferable to consider a trial of RFAP. Radiofrequency energy causes a low-temperature molecular disintegration, resulting in volumetric tissue removal with minimal collateral tissue damage.3
The treatment is performed as previously detailed withthe patients seated in the office. After achieving local anesthesia, a commercially available RFAP hand-piece connected to a 465 kHz radiofrequency device (Somnus, Inc., Sunnyvale, CA) is introduced submucosally in a midline (600 J) and two lateral locations (300 J) for three separate sequences of energy, delivering a total of 1200 J at atarget temperature of 85°C and 10 watts of power. The intended effect is the shrinkage of the soft tissues, resulting in tightening and modest shortening of the palate(Fig. 61.1).
Fig. 61.1 View of the palate of a patient who underwent laser-assisted uvulopalatopharyngoplasty (LAUP) previously (A), but has recurrence of symptoms. The patient elects to undergo rescue with radiofrequency ablation of the palate (RFAP) which is performed with multiple energy delivered sites as indicated (dotted lines). The intended effect is depicted in (B); note the modest shortening/tightening of the palate that results.
RFAP is not associated with any major complications. The salvage operation may involve the risks of attaining suboptimal results as in primary surgery. RFAP, although intended to be mucosa sparing, is nevertheless associated with a high incidence of mucosal injuries, many of which are occult.4 Mucosal edema, if it happens, settles by itself. Superficial ulceration of the soft palate was also reported.5