LASER ASSISTED UVULOPALATOPLASTY (LAUP) AND SOMNOPLASTY

Note: The language of this manuscript is quite complicated and is written partially with medical terminology, whenever possible I simplified the language or placed definitions in parenthesis. Some paragraphs that could not be translated into simple English are italicized and were left in the manuscript for those of you who either like challenge or are medically knowledgeable.

"The only disease that afflicts the un-afflicted"

DEFINITION AND Prevalence (Extent of occurrence).
Sleep apnea is a serious, potentially life-threatening condition. It is a breathing disorder characterized by repeated collapse of the upper airway during sleep, with consequent cessation (stopping) of breathing. Virtually all sleep apnea patients have a history of loud snoring. They may also unknowingly experience frequent arousals during the night, resulting in chronic daytime sleepiness or fatigue.

There are two discrete types of sleep apnea:
central and obstructive. Central sleep apnea, characterized by a lack of airflow in the absence of ventilatory (breathing) effort, (the brain forgets to send down the order "take a breath") is rare. Obstructive sleep apnea is much more common and is referred to as sleep apnea hereafter. It is characterized by closure (obstruction) of the upper airway, resulting in the cessation of airflow despite persistent ventilatory effort. Apnea is defined as cessation of airflow for more than 10 seconds. A related event, hypopnea, is characterized by a reduction in airflow associated with a decrease in oxygen saturation (the amount of oxygen found in the blood). The average number of apnea hypopnea events per hour of sleep is called the apnea-hypopnea index (AHI). Adults may experience up to five events per hour without symptoms. In general, as AHI increases, so does the severity of symptoms. An AHI of five or greater in combination with self-reported hypersomnolence (sleepiness) is indicative of the sleep apnea syndrome.’

The first reference alluding (referring to) to sleep disturbance in modern literature was Charles Dickens’ the Pickwick paper published in 1836. Sir William Osler’s recognized this syndrome in 1906 by describing a patient with obesity and hypersomnolence (marked sleepiness). Uvulopalatopharyngoplasty (the name of the procedure to remove part of the soft palate and Uvula) was first designed as a surgical treatment for snoring in 1964 and was later applied to obstructive sleep apnea in 1981. Since those time much effort has been devoted to improving the surgical treatment.

CLINICAL SIGNIFICANCE
Snoring affects approximately 50% of men and 30% of women. It is estimated that of these populations, half are habitual snorers. Snoring has long been ignored by most of the medical community and was addressed as a purely social problem primarily disruptive to family life. It can be a cause for courtship failures and marital difficulties. Snorers may be socially excluded by roommates or even housemates. Chronic snorers often report restless sleep, morning headaches, or excessive fatigue in the morning. They may demonstrate daytime listlessness and hypersomnolence. Other complications of obstructive sleep apnea and snoring include the following: memory difficulties, behavioral and affective changes, impotence, loss of alertness, and even death.

Medical complications have even been attributed to snoring without apnea. Snoring may be a risk factor for hypertension (high blood pressure), angina pectoris (chest pains), cerebral infarction (stroke), pulmonary hypertension (increased pressure in the lungs), and congestive heart failure. Conditions thought to be more commonly associated with obstructive sleep apnea.

From a behavioral standpoint, sleep apnea patients usually experience but may or may not report tiredness, fatigue, sleepiness, memory and judgment problems, irritability, difficulty concentrating, and personality changes. Patients with sleep apnea are more likely to fall asleep at inappropriate times and have a higher rate of automobile crashes and work-related accidents.

Sleep apnea is also seen in children. Tonsillar and/or Adenoid hypertrophy (enlargement) is the most common cause. Children with sleep apnea may exhibit additional signs and symptoms than adults. During sleep, children exhibit snoring and overworked breathing. Features compatible with sleep apnea include weight loss or failure to gain weight, poor school performance, poor attention span, secondary enuresis (bed-wetting), and behavioral problems.

The cardiovascular system is also adversely affected by sleep apnea. Systemic hypertension (high blood pressure) has been reported in up to 50 percent of patients with sleep apnea. Mean morning blood pressure has been shown to increase almost linearly with increasing apneic activity in both obese and non-obese individuals. Cardiac arrhythmia's (irregular heart beats) during sleep have also been associated with sleep apnea. Usually bradyarrythmias (slowdown heart beats)) are observed, although ventricular tachycardia (speedup) is noted occasionally in cases of severe hypoxemia (low oxygen level in the blood). It is possible that sleep apnea contributes to myocardial ischemia (deficiency of blood supply), and even myocardial infarction (heart attack), in patients with coronary artery disease.

A small subset of patients with severe sleep apnea could be characterized as having the Pickwickian Syndrome (also known as obesity-hypoventilation syndrome), which consists of daytime hypercapnia (high CO2) and hypoxemia, pulmonary hypertension, polycythemia, and corpulmonale.

Patients who snore may actually have obstructive sleep apnea when strict sleep study guidelines are applied. Of these patients, a significant proportion demonstrates classic obstructive sleep apnea type snoring, which is crescendo (increasing) snoring with ventilatory (breathing) pauses despite a respiratory effort.

The incidence of obstructive sleep apnea may be as high as 4% in the general population and 5% to 10% in adult males. Obstructive sleep apnea is much more common in men and in obese patients. It is rarely found in pre-menopausal women.

Symptoms

• Chronic, loud snoring

• Gasping or choking episodes during sleep

• Excessive daytime sleepiness (especially drowsy driving)

• Automobile or work-related accidents due to fatigue

• Personality changes or cognitive (mental) difficulties related to fatigue

Signs

• Obesity, especially nuchal obesity (neck size > 17 inches in males, > 16 inches in females)

• Systemic hypertension (high blood pressure)

• Nasopharyngeal narrowing

• Pulmonary hypertension (rarely)

• Cor pulmonale (rarely)

DIAGNOSIS
The diagnosis of snoring is made primarily by examining the patient’s history, much of which can be obtained from the patient’s bed partner. The character and consistency of the snoring is reviewed to determine severity and possible obstructive sleep apnea. Each patient is given a detailed survey that explores his or her medical condition, sleeping position, alcohol and sedative intake, and weight changes.

The physical examination includes a complete evaluation of the nose, nasopharynx (back of nose), oral cavity, oropharynx (back of mouth), hypopharynx (back of throat), and larynx (voice box). Flexible fiber-optic nasolaryngoscopy (exam of the airway with a special fiberoptic instrument) aids in this examination. Polysomnography (sleep study) is performed to rule out or determine the presence and severity of obstructive sleep apnea. Other upper airway studies can be obtained to evaluate a patient with obstructive sleep apnea, but none can reliably predict the precise level of obstruction.

Patients at high risk for sleep apnea are those who exhibit loud, chronic snoring. If it can be confirmed that the patient does not snore, sleep apnea is unlikely. On the other hand, patients who are observed to have apneic events characterized by choking or gasping during sleep are definite candidates for further evaluation. Bed partners or family members will likely need to be interviewed in order to obtain accurate information about snoring and apneic events.

Obesity, particularly upper body obesity, is a risk factor for sleep apnea and has been shown to have a significant effe7ct on its severity. Most sleep apnea patients are obese, when obesity is defined as greater than 120 percent of ideal body weight Large neck circumference in both male and female snorers is highly predictive of sleep apnea. In general, men with a neck circumference of 17 inches or greater and women with a neck circumference of 16 inches or greater are at a higher risk for sleep apnea.

Other signs and symptoms that can help identify patients at risk for sleep apnea are hypertension, excessive daytime sleepiness (especially dozing off while driving), automobile or work-related accidents, and otherwise unexplained pulmonary hypertension or cor pulmonale.

PATHOPHYSIOLOGY(how does it occur?)
The actual noise associated with snoring is created by relaxation and vibration of the uvula, soft palate edge, and tonsillar pillars. Obstructive sleep apnea is a collapse of the upper airway during inspiration while the patient sleeps. This collapse occurs when the negative pressure within the pharynx exceeds the ability of its walls and musculature to resist collapse. Any narrowing along the upper airway will increase the pressure and subsequently promote further narrowing or will require an increase in the velocity of airflow, further reducing intraluminal pressure (the Bernoulli effect). A redundant palate or elongated uvula can cause snoring from the rapid airflow created during inspiration. Further anatomic narrowing or obstruction anywhere along the upper airway can cause obstructive sleep apnea and physiologic dysfunction of neuromuscular and respiratory control mechanism.

TREATMENT FOR SLEEP APNEA / SNORING

The goals of treatment for sleep apnea patients include both physiologic and symptomatic components. Physiologic goals of treatment include eliminating sleep fragmentation, apneas and hypopneas, and oxygen desaturation (lowered oxygen concentration in the blood). Symptomatic goals include eliminating snoring and sleepiness, improving quality of life, and reducing or eliminating comorbidities (the other person suffering). Symptomatic improvement, particularly decreased snoring, does not necessarily correlate with physiologic improvement or decreased morbidity. Therapy decisions must be individualized and are often accomplished in consultation with sleep apnea specialists.

TREATMENT OPTIONS:
Treatment of snoring begins by eliminating or reducing causative or exacerbating (to make worse) factors. Sleeping position, avoidance of sedatives and alcohol and weight loss can eliminate mild snoring. Prosthetic and tongue-retaining devices may be effective in 60% of patients for obstructive sleep apnea and snoring but have a poor compliance rate. Bilevel positive airway pressure and continuous positive airway pressure (CPAP) require patients to wear a bulky nasal device attached to a bedside positive pressure-generating machine. The machines help maintain upper airway patency (open) in the treatment of obstructive sleep apnea. Again, the reliance on long-term use of an external device limits compliance (use of the device). However, this is the first treatment of choice for obstructive sleep apnea because it is noninvasive (not surgical) and can be continued into the postoperative period or until healing has taken place and a repeat polysomnogram (sleep study) could be performed to evaluate the results of surgery.

The surgical treatment of choice for snoring before the introduction of laser assisted uvulapalatoplasty (LAUP) and the most common procedure for obstructive sleep apnea is uvulopalatopharyngoplasty (UPPP). Uvulopalatopharyngoplasty is a maximal removal of the soft palate and tonsils, including the uvula. Nasal surgery may be necessary in patients with nasal obstruction. When nasal symptoms are the primary complaint, success of nasal surgery alone may be predicted preoperatively by the nightly use of a long-acting decongestant spray. General anesthesia is required for traditional uvulopalatopharyngoplasty.

Postoperative complications include the following: hemorrhage (2%), postoperative nasal regurgitation (20% to 60%), permanent velopharyngeal insufficiency (0. 5%), and nasopharyngeal stenosis, which is rare. Long-term minor complications include voice or resonance changes in a few patients and a foreign body sensation of "increased mucous secretions." The latter may be attributed to loss of the uvula, which sweeps the posterior pharyngeal wall clear of secretions during swallowing.

TREATMENT OF SLEEP APNEA

• Modification of behavioral factors

• Weight loss (including exercise regime)

• Avoidance of alcohol and sedatives before sleep

• Avoidance of supine (flat on back) sleep position

• CPAP (continuance positive airway pressure)

• Noninvasive

• Very effective

• Patient adherence variable

• Oral/dental devices

• May be useful in mild-to-moderate cases

• Not uniformly effective

• Surgical procedures (UPPP, nasal surgery, tonsillectomy, Adenoidectomy, LAUP, maxillofacial surgery, tracheostomy)

• Invasive

• Not uniformly effective

• May carry risk

• Repeat sleep study is necessary after each procedure

NON SURGICAL TREATMENT:

BEHAVIORAL APPROACHES
Behavioral measures may be the only treatment needed for patients with mild sleep apnea. Behavioral interventions include losing weight, eliminating evening alcohol and sedatives, and proper positioning (avoiding the supine position in bed). Although weight loss (accomplished through a comprehensive program or surgery) may be difficult to achieve, it can be very effective and, in some cases, even curative.

Patients with mild symptoms may experience improvement using behavioral techniques alone. Appropriate behavioral treatment should be implemented for all patients, even those requiring additional interventions.

For patients who have improved, continued support and positive reinforcement can sustain their adherence and success. In those patients who continue to experience symptoms, other therapies are warranted.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Continuous positive airway pressure (CPAP) is the most effective noninvasive therapy for sleep apnea. To use CPAP, the patient must wear a sealed mask over the nose or, in some cases, over the nose and mouth during sleep. The mask is connected to a blower (ventilator) forcing air through the nasal passages. CPAP acts as a pneumatic splint by increasing the pressure in the oropharyngeal airway, thereby maintaining airway patency throughout the ventilatory cycled This treatment is usually prescribed after polysomnography has first determined the therapeutic level of CPAP pressure required to reduce or eliminate sleep apnea. CPAP is effective in reversing daytime somnolence and eliminating cardiopulmonary sequelae. CPAP used properly, produces rhythmic breathing, resulting in the patient feeling dramatically better and being able to function more efficiently. Compared with no treatment or other treatment modalities (options), patients treated with CPAP have a lower mortality rate. Although very effective, CPAP may be difficult for some patients to use. Adherence to CPAP treatment varies greatly but tends to be higher in patients with severe symptoms. The most common reasons for discontinuing CPAP are intolerance of the mask, nasal related complaints, and the inconvenience of being connected to a machine. Common side effects include nasal stuffiness, runny nose (rhinitis), facial skin discomfort, and discomfort with the pressure. Humidifiers, nasal steroids or decongestants, intranasal anticholinergics, or different masks may relieve side effects. Variations in pressure application have been developed to offer patients options for improving comfort. Assisting patients to focus on symptom reversal and working with home care companies to ensure proper fitting and effective equipment will enhance adherence.

Follow-up after the first month of CPAP treatment should include checking the status of equipment, assessing patient symptoms and adherence, and assessing the status of coexisting conditions such as hypertension. In patients who have achieved significant weight loss, the CPAP pressure may need to be adjusted. If the patient reports continued snoring, the pressure may need to be increased.

ORAL/DENTAL APPLIANCES
Oral or dental appliances may be an option for patients with mild-to-moderate sleep apnea. However, they are not effective in all patients. Appliances have also been used for patients who snore but do not have sleep apnea. There are various devices that displace (move) the tongues forward or move the mandible to an anterior and forward position to improve patency (openness) of the airway. Reported side effects of the devices include excessive salivation and temporomandibular joint (the jaw joint) discomfort. A doctor, dentist, or orthodontist experienced in the use of these devices should fit the patient, and a sleep study should be done after the device is fitted to evaluate its effectiveness.

THE SURGICAL OPTIONS

Patients need to understand that no surgical procedure has universal success, and all are invasive and carry risk. Several procedures or a combination of procedures may need to be performed to help sleep apnea patients. It is important that sleep studies be repeated after each surgical procedure to confirm its effectiveness, once there is evidence of adequate healing. When considering treatment options, it is important that the patient recognize that CPAP is highly effective when used properly and is safe and reversible

UVULOPALATOPHARYNGOPLASTY (UPPP)
During UPPP, an inpatient procedure, the uvula (the long structure at the back of the mouth) and portions of the soft palate are resected (removed) to widen the oropharyngeal (back of the throat) airway. Tonsillectomy is usually performed in conjunction with the UPPP. Although snoring is temporarily relieved in most cases, apnea may persist. The overall success rate of UPPP is reported to be about 40 percent. It is difficult to predict which patients will benefit from this procedure, and long-term side effects and benefits are unknown.

NASAL SURGERY
Nasal surgery may be used alone or in conjunction with other procedures. However, it is rarely curative alone unless there is definite pathology present. The septum (midline nose divider) and / or turbinates (intra-nasal structure) may need correction.

TONSILLECTOMY. (ADENOIDECTOMY)
In children and adolescents adenotonsillectomy (removing the tonsils and Adenoids) may be useful, even curative. Tonsillectomy alone in adults is not usually helpfully but is often done in conjunction with UPPP

LASER-ASSISTED UVULOPALATOPLASTY (LAUP)
LAUP has received much attention recently as a treatment for snoring. However, its effectiveness in treating sleep apnea is unknown. LAUP differs from traditional UPPP in both surgical technique and setting (office-based). LAUP excises only part of the uvula and associated soft-palate tissues. The resultant shortening of the palate and reduction of the uvula may reduce, alter, or eliminate snoring. As with UPPP, relief of snoring may occur without improvement in apneic events. Therefore, patients who elect LAUP for snoring may risk delaying the diagnosis of sleep apnea because snoring, a primary symptom, is eliminated.

The uvula is ablated (destroyed) by 60% to 90% of its original length and thickness. The over all surgical goal is to reduce the length and reshape the soft palate and uvula. Occasional light bleeding can occur in approximately 3% of the patients. This can be easily controlled. Patients with obstructive sleep apnea who have redundant pharyngeal folds and enlarged tonsils can be helped by the reduction of the upper portion of the pharyngeal folds and the tonsils. Each session of LAUP usually takes 15 to 20 minutes to perform.

LAUP at times requires three to four treatments spaced a minimum of one month apart. At least 4 to 6 weeks should elapse between consecutive sessions to allow time for proper healing of the soft palate and correction of the obstructive sleep apnea. The endpoint of the LAUP occurs when snoring is significantly reduced or eliminated as reported by the patient or the bed partner.

Postoperative Instructions.
Patients are able to resume regular activities immediately after surgery. A soft, bland diet with avoidance of citrus fruits (acidic) and spicy meals is recommended. Excessive hydration, humidification, and steam inhalation is advised to avoid drying of the mucus membranes. Gargling with nonalcoholic mouthwashes every 3 to 4 hours for 1 week helps to relieve excessive sore throats. The need for analgesics varies according to each patient’s tolerance.

Complications.
A moderate to severe sore throat is the dominant side effect after LAUP. Pain intensity reaches its peak 3 to 5 days postoperatively with complete relief of symptoms approximately 7 to 10 days after surgery. The pain is usually controlled with hydration, anesthetic gel, and oral analgesics (pain medication). There is very mild bleeding during surgery in approximately 3% of patients. There is no late or delayed bleeding in most patients. Healing occurs by formation of an eschar (scab) 3 to 5 days after the procedure. Complete healing takes place after the slough of the eschar in approximately 10 to 12 days.. In approximately 20% of patients LAUP is combined with other procedures, such as submucous resection Of the septum (septoplasty), laser/conventional turbinectomy, laser-assisted serial tonsillectomy/tonsillectomy, or laser lingual tonsillectomy. LAUP is an effective method for treating patients with loud, habitual snoring. LAUP, performed as an office procedure under local anesthesia, has proved to be a safe. And reliable method to relieve this sociomedical problem thus far, experience has been very encouraging. Preliminary data indicate an 85% to 90% success rate by significant reduction or elimination of snoring.

MAXILLOFACIAL SURGERY (Genioglossal advancement, Maxillary and Mandibular advancement)
These are specialized procedures that are currently not widely available, although they appear to be effective in treating sleep apnea. Genioglossal advancement enlarges the airway at the base of the tongue. This procedure may be combined with a UPPP. Maxillary and Mandibular advancement enlarges the airway at the level of the soft palate as well as the tongue.

TRACHEOSTOMY
Tracheostomy (creating a "breathing hole" in the neck) is highly successful In eliminating sleep apnea but is very Invasive, both physically and psychologically. This procedure is reserved for severe cases where other treatments have failed.

PHARMACOLOGICAL TREATMENT
Currently, there are no safe and effective medications indicated in the routine treatment of sleep apnea.

OXYGEN
Administration of supplemental oxygen may improve nocturnal desaturation but is not a satisfactory treatment option by itself because it does not reduce sleep disruption and subsequent daytime sleepiness.

THE NEW "KID" ON THE BLOCK! SOMNOPLASTY

There is a relatively new revolutionary treatment in the arsenal for the treatment of patients who only snore and do not have sleep apnea, it is classified as surgery but in reality it is not, let me explain what is Somnoplasty?

Somnoplasty (an instrument) uses low-power, low-temperature radiofrequency energy to treat a well-defined area in the uvula or soft palate. The procedure takes place in the physician's office under local anesthesia, and typically takes less than thirty minutes. Radio-frequency energy is delivered beneath the surface layer of the soft palate, called the mucosa.The treated tissue is heated just enough to create an area of coagulation (type of burn). Over the next four to six weeks the treated tissue is naturally removed by the body, reducing the volume and stiffening the area responsible for your snoring There may be some swelling and discomfort for a few days following the procedure, not unlike the felling of an oncoming cold. During the next month or so you defined should experience a gradual decrease in your snoring. Depending on your level of snoring, the Somnoplasty procedure may need to be repeated. Since the delicate lining of the palate is protected, the Somnoplasty procedure is virtually painless and allows for a quick recovery.

PARTING THOUGHTS ABOUT SNORING

Many, many people snore! If you or a loved one is among those with this common problem, there is no need to feel isolated or, embarrassed. According to the American Academy of Otolaryngology - Head and Neck Surgery, 45% of normal adults snore occasionally and 25% are habitual snorers. Some researchers feel that these figures are too low in that many snorers who sleep alone either do not know they have a problem or refuse to admit it!

Snoring is more than just a social problem. Besides the obvious annoyance of keeping the snorer’s unfortunate roommate awake, the snorers themselves often do not sleep restfully and may have difficulty staying alert and awake during the day. Many snorers wake up still exhausted and stumble through the day scarcely able to keep studies have shown that chronic snorers are more likely to get divorced and more likely to have automobile accidents.

Attempts to cure snorers have been made throughout the ages. Inventors have patented some 300 devices which are intended to put a muzzle on the snorer’s nightly serenade. Most of these devices (including one which actually shocks the unwary sleeper when snoring begins) only treat the symptoms and offer no cure whatsoever. Whether described as a "freight train" or "sawing logs", the sound of 85 percent of all snorers is produced by vibration of the soft tissues of the mouth and throat when the air passages are inadequate due to various factors, including anatomical abnormalities and nasal obstructions. These are the snorers who can often be cured completely or at least enjoy drastic improvement by treatment with the laser in a new technique called: LASER ASSISTED UVULA PALATOPLASTY (LAUP) or SOMNOPLASTY.

If you have any questions about the treatment of snoring and or sleep apnea and you did not find the answers in this information packet please do not hesitate to ask Dr. Lucente or Dr. Gregory.