SALVAGE OF FAILED PALATE PROCEDURES FOR SLEEP-DISORDERED BREATHING

ADRIAN THOMAS, BS, DAVID J. TERRIS, MD, FACS

Surgical procedures designed to shorten, stiffen, or otherwise modify the palate may provide relief of upper airway collapse at the palatal level in patients with sleep-disordered breathing. For patients who fail, or suffer a relapse after an initial surgical success, salvage surgical techniques may be appropriate. Although the principles of these salvage techniques are similar to the commonly performed primary surgical procedures, subtle modifications of the approach are sometimes required, and these are emphasized herein.

More than 40 million people in the United States are affected by sleep-disordered breathing (SDB)J A number of effective surgical and nonsurgical treatments have been developed. While continuous positive airway pressure (CPAP) has emerged as a reliable treatment, it is generally poorly tolerated, and therefore the compliance is low.

Surgery offers the possibility of eradication of the dis- ease but also presents a number of drawbacks. Among them include the need to identify the site of obstruction. Localizing the level of pharyngeal collapse allows for cus- tomization of the surgery, and therefore a site-specific surgical approach. In more than 80% of patients with SDB, obstruction at the palate is identified as being at least a contributor to the overall airway obstruction. Many of these patients have multilevel pharyngeal collapse, requir- ing surgery at multiple sites. The comments here will be focused on palatal obstruction.

The uvulopalatopharyngoplasty (UPPP) procedure 2 has become a mainstay in the management of palatal collapse for patients with SDB. In addition, in an effort to decrease the morbidity of surgical treatment, several office-based surgical interventions have been developed and imple- mented for the treatment of obstruction at the palate level, including laser-assisted uvulopalatoplasty (LAUP), 3 and radiofrequency ablation of the palate (RFAP). 4 While these procedures have proven effective in treating mild SDB in short-term analyses, 4'5 the long-term evaluation of these procedures reveals a substantial rate of recurrence of both the snoring and daytime sleepiness, and in some cases a steady trend toward recurrence has been shown over time. 6-10

The salvage of patients who have undergone these pro- cedures and either failed at the palate or suffered the long-term recurrence of symptoms has received relatively little attention in medical literature. Retreatment has been considered, and reports of successful series of patients have been documented. Li et alm showed that patients who have relapsed after successful RFAP treatment may

From the Department of Otolaryngology/Head and Neck Surgery, Medical College of Georgia, Augusta, GA.

Address reprint requests to David J. Terris, MD, FACS, Department of Otolaryngology/Head and Neck Surgery, Medical College of Georgia, 1120 Fifteenth Street, Augusta, GA 30912. E-mail: dterris@mail.mcg.edu.

Copyright 2002, Elsevier Science (USA). All rights reserved. 1043-1810/02/1302-0013535.00/0 doi:l 0.1053/otot.2002.127287

be rescued with subsequent RFAP procedures with im- provement in both snoring and sleepiness. The potential for long-term recidivism following UPPP, LAUP, and RFAP, and the successful salvage of RFAP procedures with a second palate procedure, emphasize the need for technical knowledge in surgically managing patients who have failed initial palate surgery for SDB. We describe the implementation of well-known palatal interventions in patients who have been previously treated with a palatal procedure. We have found that many of these patients who have either failed initial treatment with prior palatal surgery, or suffered a long-term recurrence, may be suc- cessfully salvaged.

PALATAL SURGICAL TECHNIQUES

We consider here the use of three basic palatal surgical interventions: UPPP, LAUP, and RFAP, while recognizing that there are a number of other effective treatments, in- cluding palatal advancement, sclerotherapy, and others.

We acknowledge that virtually any permutation of pri- mary procedure and secondary salvage procedure can be considered. To illustrate the essential possibilities, how- ever, we have focused on four typical circumstances that lend themselves, primarily because of the postsurgical anatomy, to one or the other of the salvage strategies.

S A L V A G I N G LAUP WITH RFAP

Patients who have had their snoring successfully miti- gated with LAUP but have experienced a relapse may be appropriate candidates for retreatment with LAUP. If they are reluctant to suffer the discomfort associated with this procedure, or if they are experiencing any type of dyspha- gia symptoms or occasional aspiration as a result of the prior treatment, however, it may be preferable to consider a trial of RFAP.

The treatment is performed as previously detailed 11 with the patient seated in the office (Fig 1A). After achiev- ing local anaesthesia, a commercially available RFAP handpiece connected to a 465 kHz radiofrequency device (Somnus, Inc; Sunnyvale, CA) is introduced submucosally in a midline (600J) and 2 lateral locations (300J) for 3 separate sequences of energy delivery totaling 1200J at a target temperature of 85~ and 10 watts of power (Fig 1B). The intended effect is shrinkage of the soft tissues, result-

1 6 6 OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 13, NO 2 (JUN), 2002: PP 166-169~

A B C

FIGURE 1. View of the palate of a patient who underwent laser-assisted uvulopalatoplasty (LAUP) previously, but has recurrence of symptoms (A). The patient elects to undergo rescue with radiofrequency ablation of the palate (RFAP), which is performed with multiple energy delivery sites as indicated (B). The intended effect is depicted in C; note the modest shortening/tightening of the palate that results.

ing in tightening and modest shortening of the palate (Fig 1C).

SALVAGING UPPP WITH LAUP

The failed UPPP may present particular challenges in treatment because of the diminished palatal tissue (raising the risk of velopalatal insufficiency) and the substantial scar tissue that may be present. Therefore, the midline palate must be treated with respect, and operated on only rarely, and with caution. In this section, the use of LAUP is detailed. This procedure is especially suitable when the palate remains somewhat low-lying, and the relapse of symptoms is felt to be related to softening of scar tissue (Fig 2A). Lateral, through-and-through trenches are ac- complished with a CO2 laser at a relatively high setting

(20W) to minimize the lateral thermal injury (Figs 2B and 2C). Some degree of restoration of the uvular function may be accomplished along with modest shortening and sub- stantial tightening of the free edge of the palate (Fig 2D).

SALVAGING UPPP WITH REVISION UPPP

The patient who manifests significant SDB after failed UPPP, and who exhibits more severe palatal retraction (Fig 3A) may require a more aggressive surgical strategy.

Generally performed in the operating room under gen- eral anaesthesia, a revision UPPP is accomplished without the removal of additional palatal tissue. Vertical incisions are made through the lateral palate (Fig 3B and 3C), and the edges of the incisions are carefully sutured, approxi-

A o t "~ . . . . . . i r ~

FIGURE 2. This patient has undergone successful patatopharyngoplasty (A), with long-term return of symptoms. The surgical objectives will include not only retightening of the palatal tissue, but restoration of some of the function lost by prior complete resection of the uvula. Vertical through-and-through trenches are created bilaterally utilizing a CO2 laser with a back-stop handpiece (B). The wounds (C) are allowed to heal secondarily over a period of 1 to 3 weeks. The intended result includes a "neo-uvula," in addition to tightening of the lateral palate (D).

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A B C

D

#,

FIGURE 3. The higher arched palate visible in this patient (A) is reflective of a more aggressive prior palatopharyngoplasty, and therefore a more sophisticated and cautious approach is necessary. An electrocautery or other instrument is used to divide the palate laterally (B), with care taken to avoid injury to the central palatal mucosa. A typical intraoperative appearance is depicted (C). To avoid cicatricial healing, each edge of each incision is closed primarily with absorbable sutures (D). The final result should not lead to any further shortening of the central palate, but rather yields stiffening and tightening of the lateral palate only, with some restoration of a "neo-uvula."

FIGURE 4. Intraoperative photograph of a patient who failed multiple stages of treatment with radiofrequency ablation of the palate (RFAP), and who desired corrective salvage surgery (A). A standard laser-assisted uvulopalatoplasty is performed utilizing a CO 2 laser (B), with vertical lateral trenches, and uvular shortening. Care is taken to maintain a uvula (C) to minimize objectionable aspiration.

1 6 8 SALVAGE OF FAILED PALATE PROCEDURES

mating the mucosal edges in such a way as to p revent cicatricial healing (Fig 3D).

In spite of careful and atraumatic surgical technique, un impeded w o u n d healing typically results in some de- gree of lateral retraction. Nevertheless, restoration of some uvular function is usually possible (Fig 3E), and desirable palatal t ightening is the rule.

SALVAGING RFAP WITH LAUP

Patients with bothersome snoring who are successfully treated wi th RFAP but suffer a relapse may be salvaged by retreatment wi th RFAP. 1~ Those that never achieve satis- factory reduct ion of symptoms are probably better served by LAUP or UPPP. Because the degree of scar tissue in the palate is typically modes t (Fig 4A), the LAUP is usual ly straightforward, and can be per formed in the usual man- ner (described previously12), under local anesthesia in the office. Vertical lateral trenches are accomplished with a CO 2 laser, and the uvula is shor tened using a f ishmouth technique to minimize mucosal resection (Fig 4B). Satis- factory healing is typical (Fig 4C), and a high rate of success can be expected.

All four of these procedures have been successfully per formed to salvage patients who have either failed prior palate surgery or suffered a long-term relapse after ini- tially successful treatment. The success rate is lower in patients who have never achieved control of their symp- toms than in those who enjoyed successful t reatment at some point, but then experienced a relapse.

DISCUSSION

UPPP was popula r ized as a t reatment opt ion for snoring and mild sleep apnea by Fujita 2 in 1981 after he refined the technique in t roduced by Ikematsu. 13 UPPP reduces snor- ing by stiffening the pharynx and reducing pharyngea l

~4 collapsibility, and the effectiveness of this procedure for SDB has been established in studies report ing short- term follow-up. The long-term results, however , are less im- pressive, wi th a significant decline in the symptom im- p rovement (including snoring) over time, 6 and in some cases a re turn to preoperat ive levels of excessive dayt ime sleepiness. 7

LAUP, deve loped by Kamami 3 in 1990, has been used successfully for the treatment of snoring. LAUP shortens the soft palate, increasing the upper a i rway patency be-

9 h ind the palate. Additionally, scarring stabilizes the soft palate, prevent ing vibration and snoring at this level. Re- cent studies, however , have demonst ra ted that 22% of patients who repor ted a successful outcome 6 months after t reatment suffered a relapse of snoring 18 to 24 months after surgery, reducing the overall success rate f rom 71% to 55%. 8

Radiofrequency volumetr ic reduct ion of the soft palate was in t roduced as a t reatment for mild s leep-disordered breathing by Powell et al 4 in 1998. The RFAP procedure creates coagulat ion necrosis, leading to fibrosis and con- traction; this stiffening of the soft palate leads a reduct ion in snoring. 15 As wi th UPPP, RFAP yielded improvements in both objective and subjective parameters in the short- term, wi th declining success noted in long-term fol low-up studies. 1~ Patients who have relapsed after successful

t reatment have been rescued wi th subsequent RFAP pro- cedures, showing restorat ion of improvement in both snoring and dayt ime sleepiness.

While a number of potential mechanisms for the relapse of symptoms following palatal surgery have been postu- lated, it is likely that, as with other surgical scars, the gradual matura t ion and softening of the palatal scar tissue m ay lead to failure of the p rocedure and re turn of objec- tionable snoring. 1~ This softened palatal tissue may be re-operated. The addit ional scar tissue created by the sal- vage procedure may enhance the effective stiffening of the palate induced by the original procedure. Methods of rescue with reduced surgical t rauma may be appropriate, resulting in lessened pain and faster recovery. Finally, the salvage palate p rocedure can frequently be done in the office, and repeated as necessary.

CONCLUSION

Long-term relapse of symptoms that may occur after pal- ate surgery emphasizes the need for effective salvage pro- cedures. The techniques discussed are similar to those per formed primarily, and are especially effective when the initial p rocedure resul ted in at least a short-term success.

R E F E R E N C E S 1. National Commission on Sleep Disorders Research: Wake up Amer-

ica: A National Sleep Alert. Washington, DC, 2:10, 1995 2. Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic

abnormalities in obstructive sleep apnea syndrome: uvulopalatopha- ryngoplasty. Otolaryngol Head Neck Surg 89:923-934, 1981

3. Kamami YV: Laser CO2 for snoring. Preliminary results. Acta Oto- rhinolaryngol Belg 44:451-456, 1990

4. Powell NB, Riley RW, Troell RJ, et al: Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing. Chest 113:1163-1174, 1998

5. Terris DJ, Wang MZ: Laser-assisted uvulopalatoplasty in mild ob- structive sleep apnea. Arch Otolaryngol Head Neck Surg 124:718- 720, 1998

6. Hicklin LA, Tostevin P, Dasan S: Retrospective survey of long-term results and patient satisfaction with uvulopalatopharyngoplasty for snoring. J Laryngol Otol 114:675-681, 2000

7. Boot H, van Wegen R, Poublon R_M, et al: Long-term results of uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Laryngoscope 110:469-475, 2000

8. Wareing MJ, Callanan VP, Mitchell DB: Laser assisted uvulopalato- ptasty: six and eighteen month results. J Laryngol Otol 112:639-641, 1998

9. Neruntarat C: Laser assisted uvulopalatoplasty: Short-term and long- term results. Otolaryngol Head Neck Surg 124:90-93, 2001

10. Li KK, Powell NB, Riley RW, et al: Radiofrequency volumetric re- duction of the palate: An extended follow-up study. Otolaryngol Head Neck Surg 120:410-414, 2000

11. Terris DJ, Chen V: Occult mucosal injuries with rad!ofrequency ab- lation of the palate. Otolaryngol Head Neck Surg 125:468-472, 2001

12. Utley DS, Shin EJ, Clerk AA, et al: A cost-effective and rational surgical approach to patients with snoring, upper airway resistance syndrome, or obstructive sleep apnea syndrome. Laryngoscope 107: 726-734,1997

13. Ikematsu T: Study of snoring. Fourth Report, Therapy. J Jap Oto- Rhino-Laryngol 64:434-435, 1964

14. Wright S, Haight J, Zamel N, et al: Changes in pharyngeal properties after uvulopatatopharyngoplasty. Laryngoscope 99:62-65, 1989

15. Powell NB, Riley RW, Troell RJ, et ah Radiofrequency volumetric reduction of the tongue. A porcine pilot study for the treatment of obstructive sleep apnea syndrome. Chest 111:1348-1355, 1997

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