AN OVERVIEW AND TREATMENT OPTIONS, WITH SPECIAL CONSIDERATION TO THE MIDDLE EAST AND THE ARAB WORLD.
By: Paul Yazbek, M.D.
FACIAL PLASTIC SURGERY
Chronic snoring is a socially disabling problem for a large number of people, and is a frequent complaint presented to otolaryngologists. Snoring can be much more than a simple nuisance, and may signal a more significant sleep-disordered breathing (SDB) problem. SDB encompasses a spectrum of disease, from simple snoring to disturbed daytime performance, even to the bed partner, to upper airway resistance syndrome (UARS) to obstructive sleep apnea syndrome (OSAS). All result from partial to complete obstruction of the upper airway. This airway collapse can occur anywhere from the nasal valves to the hypopharynx.
Partial airway collapse and tissue vibration at the level of the palate is the usual cause of the snoring component of SDB. Treatment of the palate is usually very successful in alleviating obstruction at this level and the noise thus produced. In recent years, a number of alternative palatal procedures have been reported for office-based treatment of the palate and in the operating room under general anesthesia. These are generally offered for snoring, but some also may have application for more significant forms of SDB. They include laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), radiofrequency volumetric tissue reduction (RFVTR) of the palate, uvulopalatal flap (UPF) and others. All of these treatments attempt to reduce the vibratory component of the soft palate and uvula to reduce snoring.
NON – SURGICAL OPTIONS
The past several years have seen the development of a plethora of newly devised or modified procedures, both surgical and non-surgical, for treating upper-airway obstructive pathology. Modifications to already existing non-surgical procedures have produced changes in traditional sleep-medicine therapy: continuous positive airway pressure (CPAP) and bi-level positive airway pressure are now more commonly used, as are a newly available variety of patient interfaces. From the dental perspective, changes in the design and construction of oral appliances (patient-adjustable, custom-made oral appliances), and oral positive airway pressure, have made oral appliances appealing in the treatment of many more patients.
Despite the allure of these non-surgical therapies, tolerance for (and long-term compliance with the use of these devices can be less than optimal for many patients. The reason that patients and treating sleep physicians may desire surgical therapy then becomes apparent.
Nasal obstruction during sleep may lead to increased oral breathing and mouth opening, thus resulting in airway obstruction due to rotation of the mandible and retrodisplacement of the tongue base backward and blocking the pharyngeal airway. Nasal obstruction may also inhibit the optimal use of nasal CPAP. Three anatomic areas of the nose that may require management include the alar cartilage/nasal valve, the septum, and the turbinates. Improvement of the alar cartilage/nasal valve often requires cartilage re-shaping or grafting. The nasal septum is usually addressed by septoplasty and turbinate hypertrophy can be managed by turbinate reduction techniques. Also to be considered are sinus problems which can also be corrected by endoscopic sinus surgery.
LASER ASSISTED UVULA PALATOPLASTY (LAUP)
LAUP allows treatment of snoring and mild obstructive sleep apnea (OSA) by removing the obstruction in the airway in an outpatient setting under local anesthesia involving several sessions, usually five, spaced several weeks apart or can also be performed in one session, with all of the targeted tissue removed at one session. It involves the cutting or vaporization of palate tissue with a CO2 laser. LAUP results in eliminating or reducing snoring to a tolerable level is excellent (75-90%), and its results in the treatment of OSA can be good, but it does not accomplish quite the same thing as the UPPP. Recently, the American Sleep Disorders Association has concluded that, because current data does not demonstrate the efficacy of LAUP in sleep-related breathing disorders, it not be recommended for treatment of these disorders.
RADIOFREQUENCY VOLUMETRIC REDUCTION (RFVR) OF THE PALATE
This is a relatively new procedure for the treatment of snoring, and is undergoing testing to determine its role in the treatment of OSAS. This is an office-based procedure that results in shrinkage of the palate, and does not involve any cutting or suturing.
Somnoplasty™ involves the placement of a small needle electrode in several places of the palate under local anesthesia. Radiofrequency energy —sort of like microwave energy—is delivered through the electrode to produce a painless lesion within the tissue of the palate below its surface. As this lesion heals, it is replaced by scar tissue. As that scar tissue matures, it contracts, and the target area shrinks, which pulls the palate upward and shortens it.
Like the traditional LAUP, Somnoplasty™ is a staged procedure, with still no long term results on it, and because there is no published data on its benefit in treating significant OSA, its use is at present limited to the treatment of snoring. Moreover, it is well known that scars relax with time, and tissues and muscles become redundant with aging, so the long term results of this procedure are questionable.
Uvulopalatopharyngoplasty consists of the removal of a portion of the soft palate, uvula, the tonsillar tissues and a limited amount of the lateral pharyngeal wall. The temptation to remove excessive amount of the tissues to improve results must be resisted because the potential complications will dramatically increase. It is irreversible, thus should a problem of velopharyngeal incompetence (VPI), which is a recognized complication of uvulopalatopharyngoplasty (UPPP) or problems in speech occur, it cannot be easily corrected.
UVULOPALATAL FLAP (UPF)
The uvulopalatal flap (UPF) is a modification of the UPPP. The goal of the modification was to reduce the potential complications of UPPP including nasopharyngeal incompetence, nasopharyngeal stenosis and dysphagia. The UPF has been shown to achieve similar airway improvement as UPPP but with less postoperative discomfort. The procedure involves the retraction of the uvula superiorly toward the hard-soft palate junction after a limited removal of the uvula, lateral pharyngeal wall and the mucosa. This results in widening of the oropharyngeal airway.
In 1996, the uvulopalatal flap, or UPF, was described by Powell and Riley as a procedure performed in the operating room under anesthesia, and offered several theoretical advantages over traditional UPPP. It is potentially reversible (in case of excessive palate removal), might offer less chance of nasopharyngeal stenosis, and interferes with palatal dynamics less than does UPPP. Its postoperative appearance is virtually indistinguishable from the uvulopalatopharyngoplasty (UPPP) for new obstructive sleep apnea which is performed under general anesthesia.
In our practice, we favor this procedure because it is reversible, and if velopharyngeal insufficiency (VPI) happens, with water or food material starts escaping through the nose, it can be corrected unlike other procedures.
Another very important thing about this procedure being reversible is that, unlike in the U.S.A. and some parts of Europe, in the Midde East, the Arab world, Russia and some other countries like Germany, we have the letters KH. and GH. That we use in everyday language, and in names like Khaled, or Ghada, and if these letters are lost by surgery, we can undo our sutures and restore them for the patient.
In conclusion, snoring is a real threat, it causes heart failure, increases the risk of stroke and is an early signal of OSA, which is a serious condition, and considering the fact that we are in the Middle East, or Gulf region, the UPF operation is the best treatment option.