When initially described by Kamami, the LAUP procedure consisted of two paramedian vertical incisions extending superiorly from the free edge of the soft palate.⁵ The uvula was largely resected in order to reshape a new, shorter one. This French method was later modified by Woolford and Farrington.⁶ Their British technique involved vaporization of a strip of mucosa from the uvula to the hard palate. This area is left bare to contract and scar, resulting in increased rigidity of the velum soft tissues. The authors prefer to utilize both modifications, often in a sequential, staged fashion. The following procedure is described with a CO₂ laser, but other lasers and cutting/coagulating instruments can also be used, such as electrocautery.

The procedure is performed in an outpatient setting under local anesthesia without conscious sedation. Patients should limit their oral intake prior to the procedure to reduce the incidence of nausea and vomiting. The patient is given an appropriate antibiotic (e.g. amoxicillin) to take the day of the procedure; this is especially important if that patient has a heart murmur or valvular disease. Also, if the patient desires, a dose of an oral benzodiazepine (e.g. Valium) to reduce anxiety, but not enough to induce somnolence, can also be administered prior to the procedure.

With the patient in the upright, sitting position, a topical anesthetic spray (benzocaine) is generously applied to the oropharynx (Fig. 24.1). Next, lidocaine 1% with epinephrine (1:100,000) is infiltrated into the base of the uvula, posterior soft palate, and the superior aspect of the tonsillar pillars (Fig. 24.2). The injected volume is small (approximately 3 ml) since soft tissue distortion and added water content may compromise the surgeon’s ability to precisely shape the palate. To minimize the painful burning associated with infiltration, the lidocaine may be mixed with bicarbonate solution (9:1 ratio) prior to injection. Further anesthetic may be readministered to alleviate any discomfort during the procedure.

Fig. 24.1 Oropharyngeal exam. Note the elongated and thick uvula and webbing of the posterior pillars. (Courtesy of Dr. Andrew N. Goldberg.)

Fig. 24.2 Six injection points in the uvular base and soft palate are present. Parauvular incision as well as uvular reduction has been performed.

The authors use a CO₂ laser to perform the surgery (Lumenis 30-C CO₂ Laser, Lumenis, Inc, New York, New York). Lasers of other wavelengths can be used as well. The hand piece has a ‘backstop’ that protects the posterior pharyngeal mucosa from inadvertent injury. A typical laser setting is 20 watts with a focused beam in a continuous mode. The patient and all members of the surgical team must wear eye protection prior to laser deployment.

Initially, the laser is used to create vertical trenches in the soft palate on either side of the root of the uvula. From inferior to superior, a through-and-through incision cutting the oral and nasal mucosa of the soft palate and the intervening soft tissue is made (Fig. 24.2). The length of the trench should be guided by the patient’s anatomy. Typically, the palatal musculature is not exposed. The tip of the uvula is obliterated and made to take on the desired contour (a scanning beam is helpful but not essential for this).

Next, the thickness of the uvula and free edge of soft palate is reduced by excision of the submucosal tissue and part of the uvularis muscle. The anterior uvular mucosa is grasped and rotated superiorly so that the tissue between the oral and nasal mucosa can be reduced with a scanning laser beam. By ‘fish mouthing’ the uvula, the anterior and posterior mucosa are left intact and will heal with minimal granulation at the free edge. These tissues then subsequently scar and contract over the subsequent weeks (Fig. 24.3).

Fig. 24.3 Typical reduction in uvular size and shortening of the soft palate after first treatment.

The laser is a useful tool for this procedure mainly becausecontrolled tissue incision and obliteration can be performed with great accuracy. Especially with the protective backstop, collateral tissue damage is quite minimal. It is clear, moreover, that the surgical result and patient outcomes are technique sensitive; precision in tissue reduction and contouring is essential. Specific caution should be exercised to avoid a circumferential wound or continuous raw surface that will predispose to pharyngeal contraction and stenosis (Fig. 24.4). Extensive and imprecise mucosal obliteration will not only lead to failure of symptomatic improvement, but also increase the chance of complications.

Fig. 24.4 Extensive mucosal obliteration and circumferential soft tissue injury may result in poor outcomes and pharyngeal stenosis.

For subsequent stages, the vertical trenches can be serially recreated and extended to obtain the desired contour and symptomatic improvement (Fig. 24.5). The uvula, in general, should be conservatively addressed after the initial stage. Furthermore, the British method of soft palate mucosal vaporization can be used as an adjunct in second or third stages. The scanning beam of the laser is used with a power setting of 20W. Approximately 2cm of mucosa and submucosa on the oral side of the soft palate and uvular base is vaporized (Fig. 24.6). The underlying median raphe and palatal musculature should, however, be carefully preserved. Subsequent scarring of this bare area may result in increased rigidity of the velum so that it may resist collapse and vibration during inspiration.

Fig. 24.5 Conservative contouring of the soft palate and uvula may be performed in subsequent stages.

Fig. 24.6 The British method of anterior uvular and soft palate mucosal vaporization can be used as an adjunct in the subsequent stages. Tissue injury does not extend to the palatal musculature.

4 POSTOPERATIVE MANAGEMENT

Prior to discharge, an examination of the pharynx confirms hemostasis. A mild narcotic with acetaminophen (e.g. hydrocodone) is used for pain management and the patient maintains 5 days of oral antibiotics. The patient is instructed to avoid aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). Furthermore, a viscous lidocaine (2%) solution may be used every 2 hours as a mouth rinse to reduce the pain.

In general, this procedure produces a significant amount of postoperative pain and discomfort. Although this improves with convalescence, several days of throat pain necessitating narcotics are common. Although LAUP may be perceived as less painful than uvulopalatopharyngoplasty (UPPP), pain from both procedures is approximately equivalent in both severity and duration to UPPP.⁷ The patient should, therefore, be appropriately counseled preoperatively and treated with appropriate narcotics postoperatively.

Oral sucralfate, a drug used for peptic ulcer disease, has been recently shown to reduce pain after LAUP. Sucralfate adheres to proteins at the ulcer site and forms a viscous adhesive barrier on the surface of injured mucosa, resulting in a cytoprotective effect. When 5 ml of sucralfate (1 g/5mL) was gargled for 5 minutes every 6 hours, there was a statistically significant improvement in throat pain, oral analgesic requirement, and return to normal diet in a randomized controlled trial.⁸

Patients are typically seen in follow-up 6 weeks after each stage of the procedure. The patient’s snoring or sleep apnea symptoms are reassessed and the palate is re-examined. Most patients require two to four stages to achieve optimal outcomes. For snoring patients, this includes reduction of snoring volume and snoring time. However, for sleep apnea, goals include alleviation of daytime somnolence and overall improvement in alertness. If being performed for obstructive sleep apnea, the patient should undergo a polysomnogram 3 months after the final LAUP stage.

5 COMPLICATIONS

Although laser-assisted uvulopalatoplasty is considered a relatively safe procedure, complications including persistent foreign body sensation, pharyngeal dryness, postoperative hemorrhage, infection, palatal incompetence, taste alteration, nasopharyngeal stenosis, and even airway compromise or death can occur. The overall complication rate for the procedure is 3.5%;⁹ since a patient undergoes several serial procedures, the complication rate for a given individual may be slightly higher.

Because of the inherent vascularity of the soft palate, hemorrhage is the most common complication after LAUP and occurs in 2–3% of patients. In a study of 754 LAUP procedures by Walker and Gopalsami, 16 patients (2.1%) developed postoperative hemorrhage.^9. All of these patients bled within 48 hours of a procedure, with the vast majority occurring within 24 hours. None of the cases necessitated blood transfusion and the site of bleeding was always the apex of the parauvular vertical trench. Approximately half of the patients required no medical intervention as the bleeding ceased spontaneously. The remainder were controlled with silver nitrate cautery or suture ligation.

To minimize bleeding complications, patients are restricted from aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and other anticoagulation medication for 2 weeks before surgery. As with all surgery, the surgeon should question the patient for a history of liver disease, bleeding after previous surgery, or a family history of blood dyscrasias and bleeding disorders.

Postoperative infection is rarely seen and occurs in less than 1% of cases. Both bacterial and fungal infections may occur. Prophylactic perioperative oral antibiotics covering oral flora are administered prior to each procedure and continued for 5 days to minimize the risk of wound infection. Fungal infections, usually candidiasis, can easily be treated with topical antifungal medications should they occur.

Velopharyngeal insufficiency is also an infrequent complication of LAUP, occurring in less than 1% of cases. The vast majority of patients will have only temporary palatal insufficiency and will often lack the stereotypical hypernasal speech. Velopharyngeal stenosis may also occur in rare cases. Care must be taken to avoid circumferential scarring of the velopharynx to prevent this complication.

6 RESULTS

6.1 SNORING

The LAUP procedure has been conventionally used in the treatment of snoring without obstructive sleep apnea. The initial report on LAUP by Kamami ⁵ revealed that 77% of non-apneic snorers had complete or near-complete resolution of snoring. A follow-up study by Walker and colleagues¹⁰ echoed these results. In their series, 60% of 105 snorers had total or near-total elimination of snoring, with an additional 29% who reported partial improvement. Other studies show patient satisfaction ranging from 60% to 84%.¹ However, the surgical techniques, timing of serial sessions, and criteria for ‘cure’ differed among these studies and may limit extrapolation of this information.

Quality of life data from several studies also indicate an improvement corresponding to decreased snoring. Armstrong and colleagues demonstrated a statistically significant improvement in quality of life for the patient and bedpartner for non-apneic snorers who underwent LAUP.¹¹ Another study revealed that 72% of bedpartners were satisfied with the procedure, and close to two-thirds no longer slept in separate rooms.¹² As most patients often seek medical attention for the sake of their bedpartner, these data realize the main outcome for which they seek care.

Few studies have analyzed the long-term effectiveness of LAUP. The problem with such longitudinal assessments is the presence of other confounding variables. The patient’s body habitus, for example, may change with time or new-onset nasal obstruction may develop. Furthermore, a bed-partner’s retrospective recall of snoring severity may become unreliable over time. Mickelson and Ahuja reported an initial total to near-total improvement in snoring in 90% of their patients at 6 to 12 weeks.¹³ However, when these patients were re-evaluated after 2 years, the effectiveness was reduced to 62%. In a Thai study, Neruntarat analyzed long-term outcomes in 340 non-apneic snorers that underwent LAUP.¹⁴ Although a small portion of his cohort underwent adjunctive procedures (e.g. tonsillectomy, turbinate reduction), 75% of patients had at least a 50% improvement in their snoring after 3 years. More prospective study with standardized techniques and grading criteria is definitely necessary to reliably establish long-term effectiveness.

Patient selection is an integral element in achieving good outcomes and patient satisfaction. As mentioned earlier, careful preoperative assessment localizing the velum as the primary level of upper airway obstruction will improve success. In a similar vein, patients with a BMI under 28 kg/m² will also have more statistically significant snoring improvement than those above 28 kg/m².⁴ It is likely that patients with a higher BMI will have secondary levels of obstruction other than the soft palate, resulting in LAUP failure.

6.2 OBSTRUCTIVE SLEEP APNEA

LAUP may be a reasonable treatment option for carefully selected patients with obstructive sleep apnea. Mickelson and Ahuja ¹³ studied a cohort of 36 patients who underwent LAUP for obstructive sleep apnea. In postoperative sleep studies, the Apnea Index decreased from 14.4 to 5.8 and the respiratory Disturbance Index (RDI) decreased from 28.1 to 17.9, both of which were statistically significant. The RDI decreased by at least 50% in 39% of patients overall and 44% of patients dropped to less than 10 events per hour. Another study by Walker and associates¹⁵ confirmed these findings. Their study of 38 patients revealed that surgical response rates, as defined by 50% decrease in RDI and postoperative RDI less than 20, were seen in 47% of mild apneics, 42% of moderate apneics, and 46% of severe apneics.

There are other studies, however, that temper the enthusiasm for LAUP as a standard treatment in the sleep apnea algorithm. When evaluating 44 consecutive patients with mild to moderate OSA, Ryan and Love found that only 27% of patients had a good response to LAUP in postoperative sleep studies performed at least 3 months after intervention.¹⁶ Subjective improvements in quality of life and daytime somnolence were present, but the snoring index did not show statistically significant improvement. Moreover, 30% of their patients were worse and had an AHI twice that of their preoperative sleep study. This unusual finding also occurred in a study by Finkelstein and colleagues.¹⁷ In their study of 26 patients, 31% actually had a worsening of the post-procedure RDI. They surmised that velopharyngeal narrowing from progressive palatal fibrosis might actually aggravate obstruction in some individuals and, thereby, worsen their sleep apnea. Indeed, a review of illustrations confirms that assumption and highlights the need to avoid circumferential scarring. Long-term satisfaction after LAUP appears to be dependent on technique and patient selection, the two most crucial aspects to successful outcomes.