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This surgical procedure is designed to improve the airway behind the base of the tongue. The genioglossus muscle (the main tongue muscle) relaxes during sleep often allowing the tongue to fall back into the airway. The muscle attaches to the genial tubercle in the middle of the lower jaw. A segment of bone that includes the muscle attachment is pulled forward and stabilized.
The UPPP is a surgical procedure in which the soft palate and uvula are removed. The procedure usually eliminates snoring but only has a 40% chance of lowering the apnea hypopnea index to acceptable levels and has potential undesirable side effects. There is no way to predict surgical success.
This treatment is usually used for simple snoring. It requires multiple visits where a laser is used to reduce tissue of the soft palate and uvula.
NT Feldman1, J Berrios2
(1) , Palms of Pasadena Hospital, St. Petersburg, FL (2) , Helen Ellis Memorial Hospital, Tarpon Springs, FL.
Introduction: Palatal surgery procedures leave the majority of OSA patients inadequately treated.
Reports of the efficacy of BOT Radiofrequency ablation, Somnoplasty, in OSA have been limited to small numbers of patients who had previously undergone palatal procedures (Powell et al 1999) We
Have prospectively enrolled 35 patients dissatisfied with nasal continuous positive air pressure (CPAP)
in a protocol utilizing simultaneous UPPP and BOT Somnoplasty under general anesthesia.
Methods: To date, 35 patients who have with an apnea-hypopnea index (AHI) greater than 10/hour who expressed dissatisfaction with CPAP have undergone simultaneous UPPP and BOT Radiofrequency ablation under general anesthesia. As our confidence in the safety of the procedure has grown, we now initially administer a total of 4,000 joules of energy in 4 lesions. The patients are monitored in the hospital overnight utilizing CPAP for airway protection. Four to 6 weeks later, BOT Somnoplasty is repeated,
with an additional 4,000 joules of energy divided into 4 lesions. Follow-up sleep studies are obtained 2 months later.
Results: Nine patients have completed the protocol for the follow-up sleep study. Their body mass index (BMI) ranged from 25 to 41 with a mean of 31.8 Seven of the 9 were treated successfully with a marked reduction in AHI. The mean Epworth Sleepiness Scale (ESS) in the 9 patients dropped from 12.2 to 4.7 (p=<0.1). Interestingly, loud snoring persisted in 2 of the 7. Three patients experienced minor superficial tongue ulcerations with infection that responded to oral antibiotics. The remaining 26 patients have undergone the initial surgery, but have not yet completed the protocol.
Conclusions: Simultaneous UPPP and BOT radiofrequency ablation can be performed safely with an acceptable success rate at short-term follow-up. This protocol allows 8,000 joules to be delivered in just two treatment sessions. Post-operative fiber optic examination in the 2 patients failed the treatment suggests that persistent lateral pharyngeal wall obstruction may explain the result.
Presented at Associated Professional Sleep Societies, June 2000, Las Vegas, NV (abstract)
Marc Bernard Blumen MD (presenter); Bernard Fluery MD; Chantal Housser-Hauw MD; Fredric Chabolle MD
Suesnes France
Objectives: To evaluate prospectively the efficacy of Somnoplasty applied on the soft palate for the treatment of obstructive sleep apnea.
Methods: Patients referred or self-referred to our center for the treatment of snoring/daytime sleepiness/witnessed apnea underwent an otolaryngologic examination. A night recording was performed in all subjects. Patients who had a respiratory disturbance index (RDI) between 10 and 30 events per hours of sleep and a retrovelar site of obstruction were included. Three different treatment protocols were consecutively used: protocol A, 700 J in the midline, 350 J on each side; protocol B, 2 times 700 J just lateral to the midline and 700 J on each side; and protocol C, 700 J on the midline, 700 J on each side. We provided at most 3 treatment sessions. All patients were asked to undergo a night recording. It was performed at least 5 months after the last treatment session.
Results: Four patients in protocol A, 30 patients in protocol B, and 22 patients in Protocol C were included and treated. Some patients were lost to follow-up. Some patients refused follow-up polysomnography. Results were evaluated based on the following criteria: subjective snoring volume, Epworth sleepiness scale, RDI, lowest oxygen saturation, and body weight. Cure was defined as an RDI of less than 20/hour and a 50% reduction in the preoperative RDI.
Conclusion: In some cases, Somnoplasty applied on the soft palate may be beneficial in the treatment of sleep apnea syndrome
Somnoplasty provides a relatively painless procedure to treat habitual snoring - reducing soft-palate tissue volume in a precise minimally invasive manner. Snoring has been shown to decrease following tissue - volume reduction, and recent studies have shown post-treatment pain to range from negligible to mild. Somnoplasty is an effective and minimally invasive choice for the treatment of obstructive sleep apnea syndrome. Delivering radiofrequency energy submucosally to the base of tongue, Somnoplasty creates limited zones of coagulation beneath the tissue surface. As lesions resorb, they stiffen and reduce the tissue in the base of tongue. A study published for OSAS/UARS reported a 55% reduction in the mean respiratory disturbance index (RDI) from baseline for all subjects - with an overall mean reduction in tongue volume of 17%
Objective: Obstructive sleep apnea syndrome (OSAS) is frequently associated with upper airway obstruction at multiple levels. The best method to treat a retroglossal level remains controversial, and until recently, available procedures involved invasive surgery, which many patients and surgeons were reluctant to undertake. Temperature-controlled radiofrequency tongue base reduction (Somnoplasty) may be a less morbid alternative. Although tongue base Somnoplasty has been evaluated as a separate procedure, it has not been formally tested as an initial combined component of site-directed multilevel OSA surgery. This study is designed to investigate the safety, feasibility, and efficacy of using simultaneous tongue base Somnoplasty with other multilevel operative procedures for OSAS
Methods: This was a prospective, nonrandomized study of 10 OSAS patients with multilevel obstruction based on physical examination with supine pharyngoscopy, cephalometrics, and acoustic reflection. All patient underwent simultaneous uvulopalatopharyngoplasty (UPPP), nasal septoplasty/turbinate reduction when indicated, and tongue base Somnoplasty under general anesthesia. Two additional tongue base Somnoplasties under local anesthesia followed in-office, bringing the total tongue base radiofrequency energy delivered to 12,000 J. Perioperative morbidity was compared to that of a control group undergoing nasal correction and UPPP without tongue base Somnoplasty. Follow-up examination and questionnaire regarding treatment morbidity and OSA symptoms were conducted at 1, 3, and 7 days, and 1, 2, and 6 months, including repeat sleep studies at 2 months.
Results: At the time of this abstract submission, 4 patients have been assessed at 2 months. There is an average apnea-hypopnea index reduction of 54% to 17.3/hour and minimum oxygen saturation increase from 79% to 87%. The Epworth score went from an average of 11.25 to 5.25, daytime sleepiness from 5.5 to 1.8 and snoring from 8.1 to 1.3. Acoustic reflection showed obstructions (<2 cm_ at specific airway level) decreased from 4 to 1 at the palate and from 4 to 0 at the tongue base. There were no operative complications, and perioperative pain and dysphagia were similar to those of the control group. Data on the additional study patients and follow-up to 6-months will be presented.
Conclusion: Tongue base Somnoplasty performed simultaneously with UPPP and septoplasty/turbinate reduction is both safe and feasible in planned multilevel OSA surgery. It appears to effectively reduced the retroglossal obstructive component in selected patients.
B. Tucker Woodson MD (presenter); Tod C Huntley MD; Samuel A Mickelson MD; Lionel M Nelson MD.
Menomonee Falls WI; Indianapolis IN; Atlanta GA; San Jose CA
Objective: It is a speculated that reducing tongue base volume will improve surgical treatment outcomes for obstructive sleep apnea (OSA). Prior studies have demonstrated that partial glossectomies may reduce OSA severity. Somnoplasty (temperature-controlled submucosal radiofrequency tissue ablation) has been advocated as a minor ambulatory surgical procedure to treat tongue base. The goals of this study are to assess treatment outcomes of the procedure.
Methods: In total, 113 patients participated in a multi-institutional study of OSA treatment effectiveness. Sixty-nine patients with mild to sever OSA, despite treatment of palate and nasal obstruction, were openly enrolled. Base-of-tongue Somnoplasty was performed with patients under local anesthesia. Polysomnography and self-reported outcome measures assessed respiratory, general health, disease specific, and peri-operative quality-of life outcomes. Forty-four patients having similar inclusion criteria were nonrandomly enrolled in a nasal continuous positive airway pressure (CPAP) comparison treatment arm, which assessed sleep and quality-of life outcomes.
Results: Eighteen Somnoplasty patients have completed polysomnography follow-up. The respiratory disturbance index increased form 45.3 + 21.1 to 33.3 + 26.6 events per hour (p = 0.0061). Epworth Sleepiness Scale, (ESS) decreased from 11.9 + 5.6 to 7.8 + 4.7 (n = 29 patients, P = 0.0005). Snoring decreased from 6.2 + 2.8 to 3.5 + 3.3 (p = 0.0077). In the nasal CPAP comparison group, ESS decreased from 12.0 + 4.3 to 7.9 + 3.7 (n = 44 patients, p < 0.0001). ESS change was similar in both Somnoplasty and CPAP groups (4.2 + 4.1 vs 4.1 + 4.4, and treatment effect 0.89 vs 0.93, respectively). In the completed group, mean energy applied was 15,696 J. In 344 treatments, 11 serious treatment-related events occurred (3.2%). There were 5 suppurative tongue infections (1.4%), with 3 requiring incision and drainage.
Conclusion: Somnoplasty is a well-tolerated minor surgical procedure. It results in both significant reduction in respiratory disturbance index and clinical improvement in sleepiness. Improvement in clinical outcomes measures are similar to nasal CPAP
NB Powell, RW Riley, C Guilleminault
Objective: This pilot study investigates the new technology of radiofrequency energy (RFe), as applied to the tongue base, for the purpose of assessing feasibility, safety, and possible efficacy in the treatment of sleep-disordered breathing (SDB).
Methods: Eighteen patients with SDB, in whom at least palatopharyngoplasty had failed, were entered in this study. The mean respiratory disturbance index was 39.6, with a mean nadir oxygen (SaO2) of 81.9%. A radiofrequency electrode delivered energy to the subsurface tongue base with local anesthetic. Polysomnography, quantitative speech and swallowing studies, questionnaires, and visual analog scales were used to assess outcomes. MRI assessed changes in tongue volume.
Results: Separate RFe treatments (mean 5.5) at 4-week intervals were given (mean 1543 J for 9 minutes at 80o C), for a mean energy total of 8490 J per patient. The post treatment mean respiratory disturbance index was 17.8, and the SaO2 nadir was 88.3%. Weight increased slightly; speech and swallowing did not change. Questionnaires and visual analog scale scores showed improvement in study variables. Tongue volume was reduced by a mean of 17%. Pain was controlled by hydrocodone for 3 to 4 days. One infection was seen and resolved with incision and drainage.
Conclusion: This pilot study demonstrates feasibility, safety, and efficacy in reducing tongue volume using RFe. Additional cumulative energy may improve the cure rate for SDB.
Otolaryngology-Head and Neck Surgery, 1999, Vol. 120, No. 8, 656-664.
NB Powell, RW Riley, RJ Troell, MB Blumen, C Guilleminault
Study Objective: To investigate, in an animal model, the feasibility of radiofrequency (RF) volumetric tongue reduction for the future purpose of determining its clinical applications in obstructive sleep apnea syndrome (OSAS).
Design: The study was performed in three stages, on in vitro bovine stage and two in vivo porcine stages. The last stage was a prospective investigation with histologic and volumetric analyses to establish outcomes.
Setting: Laboratory and operating room of veterinary research center.
Participants: A homogeneous population of porcine animal models, including seven in stage 2, and 12 in stage 3.
Intervention: RF energy was delivered by a custom-fabricated needle electrode and RF generator to the tongue tissue of both the in vitro and in vivo models.
Measurements and results: Microultrasonic crystals were used to measure three-dimensional changes (volumetric reduction). Lesion size correlated well with increasing RF energy delivery (Sperman correlation coefficient of 0.986; p=0.0003). Histologic assessments done serially over time (1 h through 3 weeks) showed a well-circumscribed lesion with a normal healing progression and no peripheral damage to nerves. Volumetric analysis documented a very mild initial edematous response that promptly tapered at 24 h. At 10 days after RF, a 26.3% volume reduction was documented at the treatment site (circumscribed by the microultrasonic crystals).
Conclusion: RF, in a porcine animal model, can safely reduce tongue volume in a precise and controlled manner. Further studies will validate the use of RF in the treatment of OSAS.
CHEST, 1998, 111:1348-1355.
The hyoid bone, located in the neck, is the attachment of some tongue muscles. If the hyoid bone is pulled forward, it can open the airway space behind the tongue.
In this procedure the maxilla and mandible are advanced anteriorly and fixed in a position that maximally increases the size of the airway. The operation pulls the upper and lower jaw forward. This procedure is usually done if previous procedures have not completely improved the obstructive breathing incidents and the patient has persistent symptoms of daytime sleepiness and fatigue.
In: Chest (1999 Dec) 116(6):1519-29
OBJECTIVE: To report the efficacy of maxillomandibular advancement (MMA) surgery, with a description of several innovations, as a site- specific treatment of obstructive sleep apnea syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy.
DESIGN: Clinical series of 50 consecutive cases.
SETTING: Surgery was performed in a hospital operating room, and perioperative management was provided in an intensive care environment. Except for polysomnography (PSG), which was performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative evaluations were accomplished in a solo office private practice setting.
PATIENTS: Patients were referred for MMA evaluation when applicable conservative therapies such as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. Case selection was based primarily on the sites of disproportionate upper airway anatomy.
INTERVENTIONS: MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures.
MEASUREMENTS AND RESULTS: Obtained at a mean of 5.2 months postoperatively, revealed significant improvement in all cases. Mean BPs (n = 50) were lowered, subjective symptoms were ameliorated, and mean body mass index (n = 50) was reduced. Cephalometric analysis (n = 50), with several new modifications including standardization for phases of respiration, quantified structural changes in soft-tissue and bony landmarks. Postoperative PSG results (n = 50) showed dramatic improvement over preoperative data (n = 50), with therapeutic values similar to nCPAP (n = 42). Mean values improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, respectively), apnea- hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 6.6 vs 2.4, respectively). The success rate was 100%.
CONCLUSION: MMA is highly successful and safe and may be a definitive primary single-staged surgical treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy.
Comment in: Chest. 1999 Dec;116(6):1503-6
Comment in: Chest 1999 Dec;116(6):1503-6
Institutional address:
drprinsell@mindspring.com
Bibliography Prinsell JR
In: J Am Dent Assoc (2002 Nov) 133(11):1489-97; quiz 1539-40
BACKGROUND: Although maxillomandibular advancement, or MMA, surgery is highly successful, the indications for and staging of MMA in the treatment of obstructive sleep apnea syndrome, or OSAS, have not been settled upon.
TYPES OF STUDIES REVIEWED: The author presents a retrospective review of several published case series with inclusion criteria of 20 or more patients who underwent MMA and received documented preoperative and postoperative diagnostic polysomnography. Protocols of MMA as a primary vs. secondary operation, with and without adjunctive procedures in a site-specific approach, are compared and discussed.
RESULTS: As an extrapharyngeal operation that enlarges and stabilizes the entire veloorohypopharyngeal airway, MMA, which can be safely combined with adjunctive non-pharyngeal procedures, may circumvent the staging dilemmas associated with multiple, less successful, segmental, invasive, pharyngeal procedures. In accordance with current goals and guidelines governing OSAS surgery, MMA does not need to be limited to severe OSAS cases as a last resort after other procedures have failed but, rather, is also indicated as an initial operation for (velo-oro) hypopharyngeal narrowing.
CONCLUSIONS: MMA is a highly successful and potentially definitive primary single-staged surgery that may result in a significant reduction in OSAS-related health risks, as well as financial savings for the health care system.
CLINICAL IMPLICATIONS: The diagnosis and management of OSAS requires a multidisciplinary team approach, including a working relationship between the dentist and sleep physician. General dentists and dental specialists who participate in the management of snoring and OSAS cases should have some knowledge of basic sleep medicine.
Institutional address:
Atlanta School of Sleep Medicine
USA. drprinsell@mindspring.com
This option creates an opening in the trachea (windpipe) through which breathing can occur. This procedure is occasionally used to treat severe obstructive sleep apnea since the opening bypasses an obstruction in the airway
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