Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing.

STUDY OBJECTIVES: To evaluate pain, swallowing, speech, edematous response, tissue shrinkage, sleep, snoring, and safety (energy limits and adverse effects) following radiofrequency (RF) treatment to the palate in 22 subjects with sleep-disordered breathing. DESIGN: This investigation is a prospective nonrandomized study. Polysomnography, radiographic imaging, and infrared thermography, along with questionnaires and visual analog scales, were used to evaluate the effects of RF treatment to the palate. SETTING: Treatments were delivered on an outpatient basis at Stanford University Medical Center. PATIENTS: Twenty-two healthy patients (18 men), with a mean age of 45.3+/-9.1 years, were enrolled. All were snorers seeking treatment and met predetermined criteria: a respiratory disturbance index < or = 15, oxygen saturation > or = 85%, and a complaint of daytime sleepiness. INTERVENTION: RF was delivered to the submucosa of the palate with a custom-fabricated electrode for a mean duration of 141+/-30 s with a mean of 3.6+/-1.2 treatments per patient. Reduction of their snoring scores determined the end point of the study. RESULTS: Neither speech nor swallowing was adversely affected. Pain was of short duration (0 to 48 h) and was controlled with acetaminophen. There were no infections. Although there was documented edema at 24 to 48 h, there were no clinical airway compromises. Polysomnographic data showed improvement in esophageal pressure measurements of the mean nadir and the 95th percentile nadir (p=0.031, p=0.001) respectively, as well as the mean sleep efficiency index (p=0.002). Radiographic imaging showed a mean shrinkage of 5.5+/-3.7 mm (p< or =0.0001). Subjective snoring scores fell by a mean of 77% (8.3+/-1.8 to 1.9+/-1.7, p=0.0001) accompanied by improved mean Epworth sleepiness scores (8.5+/-4.4 to 5.2+/-3.3, p=0.0001). CONCLUSION: The results of this investigation allowed the formulation of safety parameters for RF in this defined population with mild sleep-disordered breathing. There was a documented tissue reduction and improvement in symptoms in all subjects. However, given the small sample size and short-term follow-up, these results should be confirmed by further investigation.

Radiofrequency volumetric reduction of the tongue. A porcine pilot study for the treatment of obstructive sleep apnea syndrome.

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, one 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: Microultransonic 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.

Detection of metastases from head and neck cancers.

Before treatment for head and neck malignancies is begun, a search for distant metastases (DM) is performed. The first objective of this review was to determine the accuracy of liver function tests (LFT), alkaline phosphatase (AP) tests, and chest radiographs (CXR) in detection of DM. Second, an effort was made to identify tumor characteristics which are associated with a higher incidence of DM and therefore justify the use of more precise screening tools. An analysis of 97 patients with noncutaneous squamous cell carcinomas presenting to the Stanford Head and Neck Tumor Board in 1991 revealed 17 DM in 14 patients. There were 10 pulmonary metastases, 5 bone metastases, and 2 hepatic metastases. CXR had a sensitivity of 50% and a specificity of 94% for detection of pulmonary DM. AP tests showed a sensitivity of 20% and a specificity of 98% for detection of bone DM. LFT had a sensitivity of 50% and an 81% specificity for demonstration of hepatic DM. A separate analysis of 79 patients with known DM from two hospitals showed the incidence of DM to be increased in patients who had tumors of advanced stage, advanced T status, and poor histologic differentiation and to also be increased in the presence of local-regional recurrence. There was little association of DM with N status. The sensitivity of CXR and laboratory tests, which are currently used in evaluation for DM at most cancer centers, is disappointing; these tests should be viewed as gross screening examinations. We recommend a chest computed tomography scan in the event of an abnormal CXR, a bone scan in the event of an elevated AP, and either an ultrasound or computed tomography/magnetic resonance imaging scan of the liver when elevated LFT levels are present, depending on tumor stage and differentiation.

Contemporary management of the aging brow and forehead.

Management of the aging brow and forehead has recently evolved based on available innovative technologies. Likewise, procedure-specific indications have changed based on collective surgical experiences. No longer is the approach based solely on hair pattern or degree of brow ptosis. Patients require varying combinations of brow elevation (prior to blepharoplasty), correction of brow asymmetries, and hairline-preserving forehead elevation. Some may only require excisional or paralytic procedures of the frontalis muscle (horizontal forehead creases), corrugator supercilii muscles (vertical glabellar furrows), and procerus muscle (horizontal glabellar furrows). We present a 3-year experience using a problem-specific approach. This incorporates endoscopic technology, botulinum toxin type A purified neurotoxin complex (Botox, Allergan, Irvine, CA) intramuscular injection, and traditional procedures such as the coronal, pretrichial, midforehead, and direct browlift. Current indications, patient selection, and results are also discussed.

Uvulopalatopharyngoplasty, maxillomandibular advancement, and the velopharynx.

OBJECTIVE: To evaluate the presence of velopharyngeal insufficiency (VPI) symptoms and the associated changes of the velopharyngeal anatomy in patients who underwent maxillomandibular advancement (MMA) for persistent obstructive sleep apnea (OSA) after uvulopalatopharyngoplasty (UPPP). METHODS: Preoperative and postoperative cephalometric radiographs were analyzed to assess the anatomic changes of the velopharynx. In addition, a questionnaire survey was sent to the patients between 6 to 12 months after MMA. The questionnaires evaluated the presence and extent of VPI symptoms, including nasal regurgitation while eating or drinking as well as hypernasal speech. A 10-cm visual analog scale (VAS 0-10) was included to assess the impact of VPI symptoms on the patient's quality of life. In the patients who reported VPI symptoms, telephone interviews were conducted 1 year after the survey to evaluate the changes in VPI symptoms over time. RESULTS: Fifty-two of the 65 questionnaires were returned. Five patients (9.6%) reported nasal regurgitation of liquids when drinking hastily, with 2 patients reporting the occurrences as occasional and 3 patients reporting as rare. The impact of these symptoms on the patient's quality of life was minimal (VAS 0.6 +/- 0.4). Regurgitation of food or hypernasal speech was not reported. The telephone interviews 1 year later revealed that the symptoms have completely resolved in all 5 patients. Comparison of the preoperative and postoperative cephalometric radiographs demonstrated the pharyngeal depth increase was 48% of the amount of maxillary advancement and the functional pharyngeal length increased 53% of the maxillary advancement. The functional depth of the pharynx after MMA was significantly greater in the patients with VPI symptoms (P=.01). CONCLUSION: The results of this study suggest that patients who undergo MMA for persistent OSA after UPPP have a low risk of developing VPI. If symptoms occur postoperatively, they are mild and have minimal effect on the patient's quality of life; moreover, the symptoms usually resolve over time.

Characterization of postoperative edema following laser-assisted uvulopalatoplasty using MRI and polysomnography: implications for the outpatient treatment of obstructive sleep apnea syndrome.

Laser-assisted uvulopalatoplasty (LAUP) has been introduced as an alternative to uvuloplatopharyngoplasty for the treatment of snoring. Despite limited study, the use of this procedure has been expanded to include patients with obstructive sleep apnea syndrome. Although the potential cost-savings of performing sleep apnea surgery on an outpatient basis are self-evident, concern exists regarding the safety of this practice. In an effort to characterize the risk of performing LAUP on an outpatient basis, eight patients with mild or no sleep apnea were identified and intensively studied before and after the first stage of LAUP to cure snoring. Assessment included preoperative magnetic resonance imaging (MRI) scans, polysomnography, and videoendoscopy. Each of these diagnostic studies was then repeated between 48 and 72 hours after LAUP. Complete polysomnographic data were available for seven of the eight patients. The mean ( +/- SD) preoperative respiratory disturbance index (RDI) was 11.3 +/- 10.9, and the mean oxygen saturation nadir (LSAT) was 87.7 +/- 6.2% (n = 7). The mean airway cross-sectional area at the palate (by MRI) was 49.8 +/- 22.8 mm2 (n = 8). After LAUP, the mean RDI nearly doubled to 21.7 +/- 9.9 (P > .1). The apnea index increased fourfold from 3.3 +/- 3.5 to 14.8 +/- 10.9 (P < .03). The mean LSAT remained stable at 87.4 +/- 4.1% (P > .5). The cross-sectional area of the airway decreased to a mean of 47.9 +/- 22.4 mm2 (P > .5). These data suggest that LAUP may temporarily worsen obstructive sleep apnea. Although the clinical significance of this degree of worsening is uncertain, it would be prudent to consider perioperative use of nasal continuous positive airway pressure in patients with more than mild obstructive sleep apnea who undergo ambulatory LAUP.

Obstructive sleep apnea surgery: patient perspective and polysomnographic results.

OBJECTIVE: The goal of this study was to assess the outcomes of obstructive sleep apnea (OSA) surgery based on the patient perspective and polysomnographic data. STUDY DESIGN: Fifty-six patients with severe OSA completed the 2-phase reconstructive protocol. A minimum of 6 months after the phase II surgery and after the postoperative polysomnography, questionnaires with visual analog scales (VAS 0-10) were mailed to the patients to assess their perceptions of treatment results. RESULTS: Forty-two (75%) questionnaires were returned. The mean patient age was 46.3 years. The mean respiratory disturbance index improved from 58.7 to 10.0. The mean lowest oxygen saturation improved from 76.3 to 87.3%. All 42 patients reported improved sleep (VAS 8.7). Although 10 patients reported changes in speech, the changes were insignificant, with 9 of the patients scoring 0 on the VAS (VAS 0.08 +/-0.3). Five patients reported changes in swallowing, and their VAS scores were 0.5, 0.9, 1.0, 2.7, and 6.9 (mean VAS 2.4+/-2.7). Forty patients (95%) were satisfied with their results and would undergo the reconstruction again. CONCLUSION: Surgical airway reconstruction for severe OSA is a highly effective treatment option base on the objective as well as the subjective assessment.

Obstructive sleep apnea surgery: risk management and complications.

BACKGROUND: Hypoxemia, hypertension, airway obstruction, and death have been associated with surgery for obstructive sleep apnea syndrome (OSAS). Patient analysis was undertaken to identify potential factors that could affect risk-management outcome. METHODS: One hundred eighty-two consecutively treated patients with OSAS undergoing 210 procedures were evaluated. Fifty-four factors were analyzed. RESULTS: Group characteristics included a mean age of 48.2 years, a mean respiratory disturbance index of 42.3, and a mean low oxyhemoglobin desaturation (LSAT) of 77.5%. Surgery included a combination of uvulopalatopharyngoplasty (162 patients; 77%) and maxillofacial procedures (173 patients; 82%). Patients with a respiratory disturbance index greater than 40 and an LSAT less than 80% (117 patients; 64%) were maintained on nasal continuous positive airway pressure. Thirty-nine patients (18.6% had difficult intubations. There was a positive correlation (p > 0.001) of difficult intubations, neck circumference (> 45.6 cm) and skeletal deficiency (Sella-Nasion-Point B < 75 degrees). All tubes were removed with the patient awake in the operating room with two transient episodes of airway obstruction. One hundred forty-eight of the patients (70.5%) required postoperative intravenous antihypertensive medications. Patients with a preoperative history of hypertension had a significantly increased risk (p > 0.01) of requiring intraoperative and postoperative intravenous antihypertensive medications. The mean hospital stay was 2.2 days (SD +/- 0.9). Analgesia was achieved with intravenous morphine sulfate or meperidine HCl (intensive care unit) and oral oxycodone (non-intensive care unit). There were no significant oxyhemoglobin desaturations, irrespective of severity of OSAS or obesity (mean LSAT day 1, 94.8% (SD +/- 2.4); mean LSAT day 2, 95.5% (SD +/- 1.6)). Complications included postoperative bleeding (n = 4), infection (n = 5), seroma (n = 3), arrhythmia (n = 4), angina (n = 1), and loss of skeletal fixation (n = 1). CONCLUSION: Intraoperative airway risks can be reduced by use of fiberoptic intubation in patients with increased neck circumference and skeletal deficiency. Patients with OSAS are at a significantly increased risk for hypertension. Nasal continuous positive airway pressure eliminated the postoperative risk of hypoxemia, which allowed the use of adequate parenteral or oral analgesics.

Radiofrequency volumetric tissue reduction for treatment of turbinate hypertrophy: a pilot study.

OBJECTIVES: Ideal treatment for nasal obstruction caused by turbinate hypertrophy remains in question. Medical therapy is often ineffective. Surgical procedures have associated morbidity including pain, bleeding, crusting, adhesion, infection, and dryness. Radiofrequency has recently been shown to be safe and effective in volumetric tissue reduction of the tongue in the animal model and of the palate in human beings. We prospectively evaluate the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) for the treatment of nasal obstruction caused by inferior turbinate hypertrophy. METHODS: Twenty-two consecutive patients with nasal obstruction and associated inferior turbinate hypertrophy refractory to medical therapy were evaluated for RFVTR. The study design limited the region of treatment to the anterior third of the inferior turbinate. The procedures were performed in an ambulatory facility with patients under local anesthesia. Clinical examinations, patient questionnaires, and visual analog scales were used to assess treatment outcomes. RESULTS: No adverse effects were encountered, including bleeding, crusting, dryness, infection, adhesion, or a worsening of obstruction. Mild edema was noted in all patients but was of short duration (24 to 48 hours). Posttreatment discomfort was well controlled with acetaminophen. Eight weeks after treatment, nasal breathing improved in 21 of 22 patients, with a 58.5% reduction in severity and a 56.5% decrease in the frequency of nasal obstruction. CONCLUSION: The results of this study demonstrate that RFVTR of the hypertrophic inferior turbinate is associated with minimal adverse effects. Furthermore, this new treatment modality achieves subjective improvement in patients with symptoms of nasal obstruction. However, because of the small sample size and short follow-up, future investigations are needed to fully evaluate the use of RFVTR in the treatment of nasal obstruction caused by turbinate hypertrophy.

Comparison of postoperative pain between laser-assisted uvulopalatoplasty, uvulopalatopharyngoplasty, and radiofrequency volumetric tissue reduction of the palate.

OBJECTIVES: This study compares the posttreatment discomfort between laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), and radiofrequency volumetric tissue reduction (RFVTR) of the palate through the use of visual analog pain scales and a quantitative assessment of the analgesic medication taken. METHODS: In one group, LAUP (n = 10) or UPPP (n = 9) was used to treat patients' snoring or sleep-disordered breathing (SDB), and the other group underwent RFVTR (n = 22). RESULTS: The mean numbers of days with pain after RFVTR, LAUP, and UPPP were 2.6, 13.8, and 14.3 days, respectively. Narcotic analgesics were required in the RFVTR, LAUP, and UPPP groups in 9%, 100%, and 100% of the subjects, respectively. The mean number of these days requiring narcotic pain medications for RFVTR, LAUP, and UPPP was 0.2, 11.8, and 12.4 days, whereas the total narcotic equivalent was 0.3, 7.4 and 29.6 days, respectively. CONCLUSION: RFVTR of the soft palate produced less posttreatment pain than LAUP or UPPP. LAUP and UPPP appeared to show little difference in the severity or duration of posttreatment discomfort.

Radiofrequency volumetric reduction of the palate: An extended follow-up study.

OBJECTIVE: The goal was to evaluate the effect of radiofrequency (RF) of the palate on speech, swallowing, taste, sleep, and snoring 12 to 18 months after treatment. METHODS: Twenty-two patients were evaluated by clinical examination, questionnaires, and visual analog scales. The patients with relapse of snoring were offered further RF treatment. RESULTS: After a mean follow-up of 14 months, no adverse effect was reported. Subjective snoring scores relapsed by 29% overall. Nine patients (41%) noted relapse of snoring from 2.1 +/- 1. 1 to 5.7 +/- 2.7 (P < 0.001). Eight of the patients underwent further RF treatment with a reduction of snoring from 5.8 +/- 2.9 to 3.3 +/- 3.1 (P = 0.01). CONCLUSION: The success of RF volumetric reduction of the palate diminishes with time, as with other surgical procedures of the palate. However, the minimal invasiveness of the RF provided a high patient acceptance for retreatment, and relapse of snoring can be improved.

Surgery and obstructive sleep apnea: long-term clinical outcomes.

OBJECTIVE: Outcome data on the surgical treatment of obstructive sleep apnea are, in general, based on short-term follow-up (<6-9 months). This examination was undertaken to assess long-term results. METHODS: Forty patients who underwent soft tissue and skeletal surgery were the subjects of this review. Methods of evaluation included polysomnographic variables (respiratory disturbance index [RDI], low oxyhemoglobin desaturation [LSAT]), body mass index, quality-of-life assessments, roentgenographic analysis, and complications. Statistical analysis used the SAS 6.12 system. RESULTS: Thirty-six of 40 patients (90%) showed long-term clinical success. The mean preoperative RDI, nasal continuous positive airway pressure RDI, and long-term RDI were 71.2 +/- 27.0, 7.6 +/- 5.2 and 7.6 +/- 5.1, respectively. The mean preoperative LSAT, nasal continuous positive airway pressure LSAT, and long-term LSAT were 67. 5% +/- 14.8%, 87.1% +/- 3.2%, and 86.3% +/- 3.9%, respectively. The mean follow-up was 50.7 +/- 31.9 months. The patients showed a statistically significant long-term weight gain (P = 0.0002) compared with their 6-month postoperative level (body mass index 31. 4 +/- 6.7 vs 32.2 +/- 6.3). There was a positive correlation with the amount of skeletal advancement and clinical outcome. CONCLUSION: Comprehensive evaluation and surgical treatment can result in successful long-term clinical outcome.

Evaluation of a new procedure for nasal alar rim and valve collapse: nasal alar rim reconstruction.

OBJECTIVE: A new operative technique to improve nasal valve collapse by placement of cartilage struts along the alar rim was compared with the standard nasal valve cartilage graft (NVG) technique. METHODS AND PATIENTS: A retrospective study of consecutive patients with nasal valve collapse was performed at Stanford University Medical Center. Seventy-nine patients with nasal valve collapse underwent reconstruction with either the classic NVG technique or a newly developed nasal alar rim reconstructive (NARR) procedure. The mean age of the NARR group was 50.13 years (SD +/- 9.40), with 36 men (92.3%) and 3 women (7.7%). The mean age of the NVG group was 52. 14 years (SD +/- 10.83), with 36 men (90%) and 4 women (10%). MAIN OUTCOME MEASURES: These included functional and subjective evaluation of nasal valve collapse. RESULTS: Forty patients (50.6%) underwent the NVG technique, and 39 (49.4%) received the NARR procedure. The NVG technique revealed 0% worsened, 15.0% (6/40) unchanged, 25.0% (10/40) improved, and 60% (24/40) free of obstruction. The NARR procedure revealed 2.6% worsened, 2.6% unchanged, 7.7% improved, and 87.1% free of obstruction. CONCLUSIONS: Nasal alar cartilage struts placed along the caudal alar rim offers sufficient support to the alar rim and valve area. This procedure appears to be as effective as currently available reconstructive alternatives, while being technically uncomplicated.

Surgical management of the hypopharyngeal airway in sleep disordered breathing.

The etiology of sleep disordered breathing is collapse or obstruction of the upper airway during sleep. This obstruction may be localized to one or two areas or may encompass the entire upper airway passages to include the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx. The presurgical evaluation, which includes polysomnography, a comprehensive head and neck physical examination, fiberoptic nasopharyngoscopy, and lateral cephalometric analysis is essential in directing surgical therapy in a site specific approach. The surgical procedures available to address hypopharyngeal and base of the tongue collapse include inferior sagittal mandibular osteotomy and gengioglossus advancement, hyoid myotomy and suspension, laser midline glossectomy, lingualplasty, partial glossectomy, and maxillomandibular advancement surgery. The Riley-Powell-Stanford Surgical Protocol has proven to be an effective and safe method for controlling upper airway collapse in sleep disordered breathing.

Long-term results of surgical management of sleep disordered breathing: are our patients really benefiting?

The etiology of sleep disordered breathing (SDB), which includes upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS), is collapse or obstruction of the upper airway during sleep. Surgical management was the first treatment modality available for SDB. Since the introduction of the tracheotomy to treat OSAS, there have been numerous procedures discovered to address the various sites of obstruction of the upper airway. This article reviews the long-term surgical results and may improve one's insight into the successes of surgical therapy for SDB.

Obstructive sleep apnea surgery: genioglossus advancement revisited.

PURPOSE: This study evaluated the accuracy of a genioglossus advancement (GA) technique (rectangular window) to incorporate the genial tubercle/genioglossus muscle complex (GGC) in patients with obstructive sleep apnea. METHODS: This prospective study consisted of 38 consecutive patients who underwent GA. Preoperative localization of the GGC was based on the cephalometric and panoramic radiographs, as well as digital palpation in the floor of mouth. Immediately after completion of the osteotomy, the presence of the genial tubercles and the amount of the genioglossus muscle captured in the bone flap were examined directly. RESULTS: All 38 pairs of genial tubercles were captured. Thirty-one patients had both bellies of the genioglossus muscle incorporated. Two patients had a complete belly and a partial (>50%) belly of the muscle captured. Five patients had only a portion (>50%) of both muscle bellies included. The incomplete incorporation of the muscles in the bone flap was caused by the limited lateral extension of the osteotomy beyond the genial tubercles. The causes of the limited lateral osteotomy extension included crowding of the lower incisors as well as the presence of elongated and/or medially angulated canine roots. CONCLUSION: The results of this study show that the rectangular osteotomy technique accurately captures the genial tubercles and enables an adequate amount of the genioglossus muscle to be incorporated and advanced. However, limited lateral extension of the osteotomy can result in a decreased incorporation of genioglossus muscle in some patients.