Cautery-assisted palatal stiffening operation

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Chapter 26 Cautery-assisted palatal stiffening operation

Kenny P. Pang, David J. Terris

1 INTRODUCTION

Snoring is caused by the vibration of the structures in the oral cavity and oropharynx – namely the soft palate, uvula, tonsils, base of tongue, epiglottis and pharyngeal walls. Most authorities would concur that over 80% of snoring is due to palatal flutter, caused by vibration of the uvula and the soft palate. Hence, it would be conceivable that techniques to stiffen the palate would be beneficial in reducing snoring. Different techniques using various instruments (e.g. the laser, cautery and coblator) have been used to achieve the same outcome. The palatal stiffening operation was first introduced by Ellis in 1994 ¹ and improvised by Mair in 2000.² Both authors utilized cautery to stiffen the palate. The original cautery-assisted palatal stiffening operation (CAPSO) procedure was based on stripping a ‘diamond’ shaped area of mucosa off the soft palate and uvula, with the aid of cautery under local anesthesia (Figs 26.1 to 26.4). Although good results were reported, the procedure produced a stellate puckered scar on the soft palate that resulted in tenting of the lateral pharyngeal walls and therefore narrowing of the late-ral distance between the tonsillar pillars (Fig. 26.5). These anatomic manifestations may explain why some patients did not have any clear benefit from the procedure.

Fig. 26.1 (CAPSO 1). The ‘diamond’ shaped mucosa is stripped off the uvula and the soft palate.

Fig. 26.2 (CAPSO 2). With the aid of an artery forceps and cautery, the mucosa is removed.

Fig. 26.3 (CAPSO 3). The uvulectomy is also performed with cautery.

Fig. 26.4 (CAPSO 4). The fibrotic scar starts to form as healing takes place.

Fig. 26.5 (CAPSO 5). A puckered stellate scar results that causes narrowing of the lateral pharyngeal pillars and tonsillar pillars medially, hence narrowing the oropharyngeal space.

Several of the newer methods involve the use of expensive implants or sophisticated equipment. The ideal technique would be an office-based procedure which would require no special equipment or implants, and which achieves effective results in a reliable and predictable fashion. We describe a modified palatal stiffening technique designed to create the palatal scar and fibrosis that is anatomically sounder and which results in retraction of the palate superiorly, avoiding the puckered scar and stenosis of the lateral pharyngeal walls.

2 PATIENT SELECTION

This modified CAPSO (Fig. 26.6) procedure is performed for patients with mild obstructive sleep apnea (OSA) (Apnea/Hypopnea Index (AHI) < 15) or patients who are primary snorers (AHI <5). The inclusion criteria include patients above 18 years of age, Body Mass Index (BMI) < 33, tonsil size grade 1 and 2, elongated uvula, all Mallampati grades, minimal base of tongue collapse (<25%) as seen on Mueller’s maneuver.

Fig. 26.6 (1 Oral cavity insert). Showing the uvulectomy, and bilateral vertical trenches. The horizontal strip of mucosa is removed down to muscle.

All patients undergo a thorough physical examination, nasoendoscopy, and a level I overnight attended poly-somnography (PSG). Patients also complete the Epworth Sleepiness Scale (ESS) and a visual analogue scale (VAS) for snoring before surgery and 7, 14, 30, 60 and 90 days after surgery. The sleep partner also completes a similar scale for snoring. Patients also complete a VAS for pain on postoperative days 1, 3, 7 and 14. Examination includes height, weight, neck circumference, BMI, and assessment of the nasal cavity, posterior nasal space, oropharyngeal area, soft palatal redundancy, uvula size and thickness, tonsillar size and Mallampati grade. Flexible nasoendoscopy is performed for all patients, and collapse during a Mueller’s maneuver is graded for the soft palate, lateral pharyngeal walls and base of tongue on a five-point scale.³

Outcome measures include subjective improvement in snoring based on the VAS and improvement in sleepiness as indicated by the Epworth scale. Objective changes are judged by the polysomnographic findings. The success criterion is a reduction of at least 50% of the pre-procedure AHI and post-procedure AHI below 15.

3 SURGICAL TECHNIQUE

The procedure is done under local anesthesia in the office as an outpatient. The patient is seated in an examination chair with the mouth open. Topical benzocaine (14%) is used to anesthetize the palatal region. A total of 3 ml of 1:100,000 adrenaline and 2% xylocaine is injected into three sites of the soft palate. An uvulectomy is performed (Fig. 26.7), followed by vertical cuts on either side of the uvula (Fig. 26.8), through both soft palatal arches. A horizontal rectangular strip of mucosa is removed from the soft palate (50 mm in length by 7 mm in width), down to the muscle layer (Fig. 26.9). Hemostasis is achieved with electrocautery. All patients are prescribed with anesthetic gargles (Difflam) and lozenges (Difflam), non-steroidal anti-inflammatory agents (Naproxen sodium), narcotics (like codeine), and cyclo-oxygenase-2 inhibitors. The co-blator technique may also be used as an instrument for this technique.

Fig. 26.7 (2 Oral cavity). Uvulectomy is performed.

Fig. 26.8 (3 Oral cavity). Bilateral vertical trenches are created through-and-through mucosa and muscle.

Fig. 26.9 (4 Oral cavity). Horizontal strip of mucosa is removed down to muscle. The edges may be apposed with absorbable Vicryl 3/0 suture.

With the healing process, as the palatal tissue heals, a fiberoptic palate results and retracts superiorly, with the oropharyngeal airway widened superiorly (Fig. 26.10).

Fig. 26.10 (5 Oral cavity). Final result showing superior retraction and fibrosis of the soft palate resulting in a larger oropharyngeal airway.

4 POSTOPERATIVE MANAGEMENT AND COMPLICATIONS

All patients are monitored in the recovery room for a further 30 minutes, with monitoring of their blood pressure, pulse rate and oxygen saturation. They are given adequate analgesia in the form of anesthetic gargles (Difflam)and lozenges (Difflam), non-steroidal anti-inflammatory agents (Naproxen sodium), narcotics (like codeine), and cyclo-oxygenase-2 inhibitors. All patients are advised to take adequate oral fluid hydration and soft blended diet in the first postoperative week.

Complications from this procedure are rare. However, primary or secondary hemorrhage is possible. Other potential complications that are very rare include velopharyngeal incompetence, fistula of the soft palate and nasopharyngeal stenosis.

4.1 SUCCESS RATE OF PROCEDURE

In this series, there were 13 patients who underwent this procedure for management of their snoring or mild OSA. All 13 patients were males, with a mean age of 35.7 years old (range of 24 to 47 years old). The mean BMI was 28.4 (range of 21.6 to 31.2). All patients were classified as Fried-man stage II and III,⁴ with tonsil size 0, 1 or 2. The mean preoperative AHI was 11.6 (range of 3.5 to 14.8), with a mean preoperative Apnea Index (AI) of 5.6 (range 0.5 to 9.1). The mean preoperative lowest oxygen saturation (LSAT) was 91.4% (range of 88% to 94%). All patients had a 3-month postoperative polysomnogram done. There were five patients who were simple snorers (mean AHI of 3.9) and eight patients who had mild OSA (mean AHI of 12.3).

The mean operative time was 15.6 minutes (range 12 minutes to 25 minutes). There were no complications of velopharyngeal incompetence, fistula, primary or secondary hemorrhage.

All patients (13/13) had reduction in their snoring intensity. The patients and their sleep partners were satisfied with the result at 3 months postoperatively. The VAS showed gradual reduction in the snoring intensity with time, ranging from a preoperative level of 8.3 (range 7.5 to 9.1) to a low of 3.3 (range 2.5 to 4.6) at 90 days postoperative.

Improvements were also noted in the Epworth Sleepiness Scale which decreased from 12.2 (range 8 to 15) to 8.9 (range 5 to 13) at 90 days postoperatively, although two patients (25.4%) did not subjectively improve. Subjectively, most patients felt that they experienced more dreams during their sleep, and much less choking sensation at night. Pain was the most common complaint. The VAS revealed significant pain, which reached a maximum on day 2 (mean of 8.6, range 7.3 to 9.1). The pain score reduced to a mean of 2.2 (range 1.8 to 3.6) at day 14.

Objective polysomnographic improvements were noted in six out of the eight patients (75%) with mild OSA. The mean preoperative AHI improved from 12.3 to 5.2 postoperatively (P<0.05). The lowest oxygen saturation improved from 88.3% to 92.5% (P<0.05). There were, however, no improvements in the proportion of slow wave sleep (SWS) or rapid-eye movement (REM) sleep. None of the patients suffered worsening of their AHI.

Mair and Day ² reported a 77% success rate for reduction of snoring in 206 patients, at 1 year, who underwent the cautery-assisted palatal stiffening operation (CAPSO). Ellis¹ similarly revealed excellent results with this procedure. Kamami first described the laser-assisted uvulopalatoplasty (LAUP)⁵ for patients with snoring. Kamami studied 417 snorers who underwent LAUP and found a reduction of snoring in 95% of the patients, after 1 year. Most authors report modest improvement after LAUP for patients with mild OSA, although a success rate as high as 75% was described by Walker et al.⁶

By combining the use of cautery with the principles of the laser palatoplasty technique and the creation of a horizontal denuded mucosal strip on the soft palate, in order to create a superior scar tissue. In this small cohort of simple snorers and patients with mild OSA, there were improvements in the VAS for snoring and the Epworth Sleepiness Scale. Most of the sleep partners were also happy with the reduction in snoring intensity at 90 days post-procedure. Subjectively, many patients reported improvements in daytime sleepiness and felt that they were no longer tired during the day. The frequency of choking sensation and gasping at night had also reduced and patients reported more dreams during their sleep. All patients had improvements in their AHI and LSAT; however, there was no significant increase in the SWS and REM sleep. The results reflect the scarring and fibrosis of the soft palate and the ‘pull’ of the scar superiorly that shortens and stiffens the soft palate. The effect is also enhanced by the shortening of the soft palate which increases the anteroposterior distance of the velopharynx.

The advantages of this procedure are that:

1. it produces a superior scar that pulls the entire soft palate upwards, in order to expand the oropharyngeal airway;

2. it is done as an office-based procedure on an out-patients basis;

3. it is low-cost and requires no special equipment nor implants; and

4. the results are excellent.

Patient selection is prudent: patients who are simple snorers and patients with mild obstructive sleep apnea, with primarily retropalatal flutter and/or obstruction, with small tonsils and BMI < 33, will benefit from the modified CAPSO technique.

REFERENCES

1. Ellis PD. Laser palatoplasty for snoring due to palatal flutter: a further report. Clin Otolaryngol Allied Sci. 1994;19(4):350-351.

2. Mair EA, Day RH. Cautery-assisted palatal stiffening operation. Otolaryngol Head Neck Surg. 2000;122(4):547-556.

3. Terris DJ, Hanasono MM, Liu YC. Reliability of the Muller maneuver and its association with sleep-disordered breathing. Laryngoscope. 2000;110:1819-1823.

4. Friedman M. Clinical staging. Uvulopalatopharyngoplasty. In: Snoring and Obstructive Sleep Apnea, 3rd edn, Chapter 9, Section 9.2. Fairbanks DNF et al., eds. Lippincott Williams & Wilkins; 2003:120–27.