Eur Arch Otorhinolaryngol DOI 10.1007/s00405-015-3722-6
RHINOLOGY
An absorbable thread suture technique to treat snoring Jang-Woo Kwon1 • Tae-Hoon Kong1 • Tae-Hyoung Ha1 • Dong-Joon Park1
Received: 9 April 2015 / Accepted: 6 July 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract We investigated a novel, minimally invasive surgery that uses an absorbable suture technique to treat snoring and mild obstructive sleep apnea. This simple procedure was developed to increase the stiffness of the soft palate and to promote uvula elevation with sutures. Thirty-five snorer and mild obstructive sleep apnea syndrome patients were included in this study. The palate was sutured with the newly developed technique. The results of our surgery were evaluated using polysomnography (PSG), the Epworth sleepiness scale (ESS), and a visual analogue scale (VAS) before surgery and 90 days after surgery. One year after surgery, telephone interviews were performed to assess patient satisfaction. Postoperative physical examinations of all patients showed increased stiffness of the soft palate and superiorly displaced uvula. These findings were consistent after the postoperative day 90. The patients’ snoring symptoms and their bed partners’ complaints, assessed by ESS and VAS, significantly improved compared to the pre-treatment value (p \ 0.05). Additionally, the apnea–hypopnea index (AHI), assessed by PSG, was significantly improved compared to the pre-treatment value (p \ 0.05). Based on the results from the telephone interviews analyzed 1 year after surgery, about 88 % of patients were satisfied with the outcome. This minimally invasive snoreplasty that uses absorbable suture material is an effective and simple procedure for treating snoring and mild obstructive sleep apnea.
& Dong-Joon Park [email protected] 1
Department of Otolaryngology-Head and Neck Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon 220-701, Republic of Korea
Keywords Snoring Obstructive sleep apnea Soft palate Uvula muscle
Introduction Simple snoring occurs in 20 % of the adult population and in 50 % of individuals age 60 years or older. Snoring is more prevalent among men, and it is related to age and obesity [1]. The prevalence rate of obstructive sleep apnea is 2–4 % in the middle-aged population [2]. Snoring and obstructive sleep apnea occur when the upper airway, including the nasal cavity, pharynx, and larynx, repetitively narrows or collapses [3]. The collapsed area can be divided into the velopharynx, oropharynx, tongue base, and epiglottis. The most commonly collapsed area is reported to be the velopharynx [4]. Surgical treatments of the soft palate include volume reduction surgery that uses radiofrequency to increase soft palate stiffness through fibrosis [5]. Recently, palatal implants were developed and have been applied to increase soft palate stiffness by reducing vibration and collapse [6]. However, side effects after surgery such as pain, inflammation, and foreign body sense persist and caused extrusion in up to 25 % of cases [6–24]. Although surgical treatment limited to the soft palate has not been perfected, this approach has been proposed to treat snoring and obstructive sleep apnea, and there are a number of studies that indicate the importance of palatal surgery. Our study is based on the principle of tissue fibrosis and increased stiffness. We designed a minimally invasive surgical procedure using absorbable sutures to minimize side effects and to achieve improvements in snoring. Our objective was to introduce this surgical method and report its clinical usefulness and possible complications.
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Eur Arch Otorhinolaryngol
Subjects and methods Subjects We conducted this study on 35 snorer and mild obstructive sleep apnea syndrome patients who underwent this minimally invasive palatal surgery. The study was conducted at one site between January 2012 and January 2013 and was reviewed and approved by the local institutional review board (YWMR-14-8-066). Informed consent was obtained from each subject. Patients who were simple snorers without apnea or hypopnea and who had mild obstructive sleep apnea syndrome (OSAS) with a 5–15 apnea–hypopnea index (AHI) were selected. We performed Mu¨ller’s maneuver and physical examinations to select patients who were thought to have palatal collapse or fluttering as the main cause of snoring and mild OSAS. We excluded patients with an AHI of 15 or higher, nasal polyps or an obvious deviated nasal septum, patients with a history of oropharyngeal surgery, and patients with other conditions that could make snoring worse, such as moderate to severe tonsillar hypertrophy. We also excluded patients who were pregnant, on psychoneurotics, or who did not have a spouse to report their snoring. Methods The surgeries were performed under anesthesia, 10 cases received local anesthesia and 25 cases received general anesthesia. For cases with local anesthesia, the patients visited the outpatient clinic to undergo a preoperative preparation, and 4 % lidocaine was sprayed on the soft palate and oropharynx. This lidocaine administration was used to anesthetize the surgical site and prevent gag reflex during the surgery. In addition, we injected xylocaine (mixture of lidocaine and epinephrine of 1:100,000) at 0.5–1 cm above the uvula, followed by consecutive injections 1.5 cm above, left, and to the right of the previous injection site. We made a minimal incision at 0.5 cm and at 1.5 cm above the uvula in the mucosa of the soft palate. The suture was started at the mucosal incision site and continued to the mid-uvula, using polyglactin 910 (VicrylÒ) #3-0 (Ethicon, Somerville, NJ), and the needle and thread were passed through the palatopharyngeus and uvula muscles. The secondary suture was started at the out-point of the needle to the tip of uvula so the suture material would not be exposed. Next, we sutured two more times from the bottom of the uvula to the first mucosal incision site in a reverse direction using the same method and finally tied the suture thread at the incision site. With the tension of the tie, the lower margin of the uvula and soft palate were elevated, and the soft palate stiffness increased (Fig. 1). The
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Fig. 1 Operative technique. a Suturing was started at the mucosal incision site. The needle and thread were passed through palatopharyngeus and uvula muscles, and then exited the oral mucosa. ` The needle re-entered the out-point site of the needle. ´ At the lowest point of the uvula, the suture was directed superiorly using the same method. ˆ The needle re-entered the out-point site of the needle. ˜ The suture ended at the incision site and was tied to the other side of thread, and then the mucosal incision site was closed. b Crosssectional schematic design of the technique. c Immediate postoperative photograph. Snoreplasty using an absorbable suture technique immediately elevated the uvula and increased soft palate stiffness (arrow)
Eur Arch Otorhinolaryngol
surgical process under general anesthesia was the same as that under local anesthesia. Survey Epworth Sleepiness Scale (ESS) was used to assess 35 patients prior to and 3 months after the surgery to determine symptom improvements. A 10 cm Visual Analogue Scale (VAS) that reflects the seriousness of snoring was given to the spouses of the patients. We also conducted a telephone interview of the surgery patients 1 year after the procedure and asked whether or not they were satisfied with the surgery results. Postoperative polysomnography Postoperative polysomnography was performed on seven patients that consented to comparison and analysis of AHI, oxygen saturation, sleep efficiency, percentage of sleep stages 3 and 4, and percentage of rapid eye movement (REM) sleep. Statistical analysis Statistical analysis of the results was carried using SAS 9.2 Ver. (SAS Inc., Cary, NC, USA), conducting paired t tests for continuous parametric data (AHI, Lowest SaO2, Sleep efficiency, %Stage 3, 4, and %REM) and Wilcoxon signedranks test for nonparametric data (VAS and ESS). A p value \0.05 was considered significant.
Results The average age of the 35 patients was 34 years, and there were 22 male and 13 female patients. The average body mass index was 28.5 ± 5.6 SD (Table 1). The postoperative pain was minor so the patients were able to adhere to a
Table 1 Demographic characteristics of the study population n = 35 Age (years)
34.2 ± 14.17
Sex Men Women BMI, kg/m2 AHI, per hr
22 13 28.5 ± 5.6 6.63 ± 2.41
Simple snoring
9
Mild OSAS
26
BMI body mass index, AHI apnea–hypopnea index, OSAS obstructive sleep apnea syndrome
normal diet. None of the patients suffered postoperative hemorrhage or severe edema. In comparing preoperative outcomes, it was obvious that the uvula was superiorly positioned and the stiffness of the soft palate had increased 1 day after the surgery. At 3-month post-surgery, superior positioning of the uvula and soft palate stiffness slightly decreased compared to the positioning 1 day post-surgery. However, a more elevated uvula position and greater palatal stiffness were noted compared to the preoperative status (Fig. 2). It was expected that the suture material would be nearly absorbed during the 3 months of recovery. However, the superior position of the palate may have been caused by fibrosis of the surrounding tissue as the suture material was absorbed. The ESS score decreased from preoperative 7.94 ± 2.31 SD to 5.06 ± 3.01 SD postoperatively, and this was statistically significant (p \ 0.05) (Fig. 3). The VAS conducted by the spouses before and 3 months after surgery indicated improvement in snoring after surgery, with a significant average decrease from 8.74 ± 2.28 SD to 4.14 ± 1.68 SD (p \ 0.05) (Fig. 4). Postoperative polysomnography was performed on the seven patients who consented. Preoperative AHI decreased from 6.06 ± 3.40 SD to 4.66 ± 2.04 SD postoperatively, and this was statistically significant (p \ 0.05). The lowest saturation increased from 89.43 ± 1.99 SD to 90.14 ± 2.67 SD, but this was not statistically significant. REM sleep increased from a preoperative value of 16.60 ± 3.27 SD to postoperative 17.47 ± 3.26 SD, and this result was statistically significant (p \ 0.05) (Table 2). Based on a telephone interview of 35 patients 1 year after the surgery, 31 patients (88 %) were satisfied with the surgery results.
Discussion Although various methods have been applied to treat simple snoring and mild obstructive sleep apnea, the basic principle of treatment is similar to approaches for moderate to severe obstructive sleep apnea. Widening the obstructive site and restricting fluttering tissue are the most important and principal mechanisms. Surgery, implants, oral appliances, and CPAP have been applied for those purposes. Additionally, the treatment method is selected based on patient anatomy, polysomnography, and patient preference, because there are many different operative indications and implications [25]. UPPP (uvulopalatopharyngoplasty), one of the most typical surgical methods, removes some amount of oropharyngeal mucosa. However, this can cause postoperative adhesion, hemorrhage, and pain [26]. LAUP (laserassisted uvulopalatoplasty) is a method designed to address
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Fig. 3 Epworth Sleep Scale (ESS). The mean ESS score decreased from 7.94 to 5.06 (p \ 0.05)
Fig. 4 Visual Analogue Scale (VAS). The mean VAS score decreased from 8.74 to 4.14 (p \ 0.05)
Fig. 2 a Preoperative photograph. The lower third of the uvula cannot be seen. b One day after surgery. The uvula is markedly elevated. c Three months after surgery. The uvula shows superior positioning, and stiffness of the soft palate is increased compared to the preoperative status. The entire uvula is visualized
these problems but is also accompanied by postoperative edema and pain, oral dryness, persistent foreign body sense, and adhesion in the oro- and nasopharynx [27]. These symptoms are considered to be caused by excessive excision of the palate and loss of physiologic function of the uvula [28]. To address these shortcomings, palatal implants (Medtronic, Minneapolis, MN), which are advantageous because
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of the relatively simple procedure, short recovery period, and less reported pain, have been developed and implemented [6]. However, this method can produce side effects such as extrusion, postoperative pain, inflammation, foreign body sense, and uneasiness when speaking or swallowing [6–24]. The surgical method adapted in this study was designed based on the principle of increasing stiffness through fibrosis, and we adopted minimal incision and used the absorbable suture material polyglactin 910 (VicrylÒ) to minimize postoperative hemorrhage, pain, collapse, and foreign body sense. The surgical target of this method is the soft palate, which is considered desirable for patients who have low soft palatal positions or a saggy soft palate and uvula with no narrowing in the nasal cavity, oropharynx, tongue base, or epiglottis. This method was influenced by the uvula muscleshortening method [29], which is a minimal invasive surgery to treat snoring and was developed in our institute.
Eur Arch Otorhinolaryngol Table 2 Comparison between preoperative and postoperative PSG data (n = 7)
No.
Sex
Age
AHI (per/hr)
Lowest SaO2 (%)
Sleep efficiency (%)
%Stage 3, 4
%REM
Pre
Post
Pre
Post
Pre
Post
Pre
Pre
Post
Post
1
M
43
3.5*
3.3*
92
94
88.4
89.4
2.4
2.3
10.5*
11.2*
2
F
42
4.6*
4.4*
92
92
58.3
60.1
14.6
15.1
19.8*
18.7*
3
F
24
12.9*
8.6*
88
87
52.7
54.2
16.2
16.31
15.8*
16.9*
4
F
53
8.2*
6.2*
87
87
90.9
91.2
0
2.7
16.9*
17.9*
5
M
20
4.8*
3.2*
89
90
83.6
83.7
8.1
8.3
17.5*
19.2*
6
M
43
3.6*
3.4*
88
89
88.6
87.6
5.7
5.6
15.4*
16.6*
7
F
42
4.8*
3.5*
90
92
75.6
76.9
15.7
17.5
20.3*
21.8*
Pre preoperative, Post postoperative, Lowest SaO2 lowest O2 saturation, PSG polysomnography, AHI Apnea–Hypopnea index, %stage 3, 4 percentage of sleep stages 3, 4 sleep, %REM percentage of rapid eye movement (REM) sleep * Statistically significant result (p \ 0.05)
Briefly, the uvula muscle-shortening methods selectively resect the middle part of the uvula muscle and induce shortening by suturing. Such methods have been associated with fewer complications and increased patient satisfaction compared to other existing palatal surgery methods [29]. However, resectioning the uvula muscle often requires normal gland removal due to intermixing with uvula muscle. Although the function of the glandular tissue is unclear, it seems more physiologic to avoid resection of normal tissue as much as possible. With tissue preservation in mind, we designed minimally invasive snoreplasty with absorbable thread. There is a possibility for symptom recurrence if the absorbable material and fibrosis dissolve completely over time. However, this simple and reversible method can be repeated easily. Even though the procedure was performed under general anesthesia in some patients, this procedure can now be performed at the outpatient department (OPD) base. Additionally, this procedure can be performed repeatedly, whenever symptoms present, similar to Botox or Filler injection procedures in cosmetic clinics. The ESS decreased from 7.94 to 5.06, which indicated postoperative patient satisfaction. Although this result is statistically significant, the decreased was not dramatic. This could be attributable to the fact that the characteristic of the ESS survey is to examine subjective symptoms of obstructive sleep apnea and not simple snoring. The VAS used to examine subjective discomfort of the spouses in regard to partner snoring also showed significantly decreased scores. However, although postoperative satisfaction of the spouses increased, considering the average value of VAS (4.14 ± 1.68 SD), some symptoms still persisted. This was also considered to have resulted from incomplete exclusion of multi-level obstructive sleep apnea patients, which occurred in the process of selecting snoring patients that only had palatal lesions based on Mu¨ller’s maneuver and physical examinations.
In addition, patients with the lowest O2 saturation level showed minor postoperative increases, but this result was not statistically significant. This could be due to the fact that the surgical method was conducted on simple snorers and mild obstructive sleep apnea patients with minimally decreased O2 saturation, thus resulting in minor postoperative changes in the lowest O2 saturation. When we compared our results with of those of previous reports, radiofrequency-assisted palatoplasty achieved a decrease in AHI of 28–81 %, VAS of 25–62 %, and ESS of 28–60 % [30]. For palatal implants, the results were a decrease in AHI of 12–34 %, VAS of 25–66 %, and ESS of 5–43 % [31]. On average, our method decreased AHI by 23 %, VAS by 52 %, and ESS by 36 %, showing similar results to the conventional methods. Snoreplasty using absorbable thread is a relatively simple procedure compared to existing soft palate surgery approaches. This technique can be performed with local anesthesia and simple surgical tools and is reversible because it uses absorbable thread and minimal incisions. There were no complaints of foreign body sense or xerostomia. However, this study was limited because this method was applied to patients who had soft palate lesions and was not applied to multi-level obstructive sleep apnea patients. Additionally, this procedure cannot be conducted on patients who have moderate to severe obstructive sleep apnea. The postoperative follow-up period was relatively short. To address this issue, a continuous, long-term follow-up study is needed in the future. Thus, additional research should be conducted to determine exact timing for reoperation. In conclusion, this minimally invasive snoreplasty used absorbable thread and is an effective and simple procedure for treating simple snoring and mild obstructive sleep apnea patients. This procedure minimizes shortcomings of existing surgical methods, can be performed at a lower cost, and was associated with increased patient satisfaction.
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Eur Arch Otorhinolaryngol Compliance with ethical standards Funding This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (20100022048). Conflict of interest of interest.
The authors declare that they have no conflict
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15. Maurer JT, Verse T, Stuck BA, Hormann K, Hein G (2005) Palatal implants for primary snoring: short-term results of a new minimally invasive surgical technique. Otolaryngol Head Neck Surg 132:125–131. doi:10.1016/j.otohns.2004.09.015 16. Friedman M, Schalch P, Lin HC, Kakodkar KA, Joseph NJ, Mazloom N (2008) Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 138:209–216. doi:10.1016/j.otohns.2007.10.026 17. Nordgard S, Stene BK, Skjostad KW, Bugten V, Wormdal K, Hansen NV, Nilsen AH, Midtlyng TH (2006) Palatal implants for the treatment of snoring: long-term results. Otolaryngol Head Neck Surg 134:558–564. doi:10.1016/j.otohns.2005.09.033 18. Walker RP, Levine HL, Hopp ML, Greene D, Pang K (2006) Palatal implants: a new approach for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 135:549–554. doi:10. 1016/j.otohns.2006.02.020 19. Nordgard S, Wormdal K, Bugten V, Stene BK, Skjostad KW (2004) Palatal implants: a new method for the treatment of snoring. Acta Otolaryngol 124:970–975. doi:10.1080/ 00016480310017090 20. Steward DL, Huntley TC, Woodson BT, Surdulescu V (2008) Palate implants for obstructive sleep apnea: multi-institution, randomized, placebo-controlled study. Otolaryngol Head Neck Surg 139:506–510. doi:10.1016/j.otohns.2008.07.021 21. Rotenberg BW, Alsaffar H, Kandessamy T (2010) Patient outcomes after soft palate implant placement for treatment of snoring. J Otolaryngol Head Neck Surg 39:323–328 22. Goessler UR, Hein G, Verse T, Stuck BA, Hormann K, Maurer JT (2007) Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea. Acta Otolaryngol 127:527–531. doi:10.1080/00016480600951392 23. Nordgard S, Stene BK, Skjostad KW (2006) Soft palate implants for the treatment of mild to moderate obstructive sleep apnea. Otolaryngol Head Neck Surg 134:565–570. doi:10.1016/j.otohns. 2005.11.034 24. Kuhnel TS, Hein G, Hohenhorst W, Maurer JT (2005) Soft palate implants: a new option for treating habitual snoring. Eur Arch Otorhinolaryngol 262:277–280. doi:10.1007/s00405-004-0791-3 25. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD (2009) Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 5:263–276 26. Kezirian EJ, Weaver EM, Yueh B, Deyo RA, Khuri SF, Daley J, Henderson W (2004) Incidence of serious complications after uvulopalatopharyngoplasty. Laryngoscope 114:450–453. doi:10. 1097/00005537-200403000-00012 27. Madani M (2004) Complications of laser-assisted uvulopalatopharyngoplasty (LA-UPPP) and radiofrequency treatments of snoring and chronic nasal congestion: a 10-year review of 5,600 patients. J Oral Maxillofac Surg 62:1351–1362 28. Zohar Y, Finkelstein Y, Strauss M, Shvilli Y (1993) Surgical treatment of obstructive sleep apnea. Technical variations. Arch Otolaryngol Head Neck Surg 119:1023–1029 29. Seo JO, Kwon JW, Kim SK, Kim SI, Park DJ (2009) Musculus uvulae shortening for the treatment of snoring. J Rhinol 16:26–30 30. Veer V, Yang WY, Green R, Kotecha B (2014) Long-term safety and efficacy of radiofrequency ablation in the treatment of sleep disordered breathing: a meta-analysis. Eur Arch Otorhinolaryngol 271:2863–2870. doi:10.1007/s00405-014-2909-6 31. Choi JH, Cho JH (2011) Effect of palatal implants on snoring and obstructive sleep apnea syndrome. J Rhinol 18:89–93
RHINOLOGY
An absorbable thread suture technique to treat snoring Jang-Woo Kwon1 • Tae-Hoon Kong1 • Tae-Hyoung Ha1 • Dong-Joon Park1
Received: 9 April 2015 / Accepted: 6 July 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract We investigated a novel, minimally invasive surgery that uses an absorbable suture technique to treat snoring and mild obstructive sleep apnea. This simple procedure was developed to increase the stiffness of the soft palate and to promote uvula elevation with sutures. Thirty-five snorer and mild obstructive sleep apnea syndrome patients were included in this study. The palate was sutured with the newly developed technique. The results of our surgery were evaluated using polysomnography (PSG), the Epworth sleepiness scale (ESS), and a visual analogue scale (VAS) before surgery and 90 days after surgery. One year after surgery, telephone interviews were performed to assess patient satisfaction. Postoperative physical examinations of all patients showed increased stiffness of the soft palate and superiorly displaced uvula. These findings were consistent after the postoperative day 90. The patients’ snoring symptoms and their bed partners’ complaints, assessed by ESS and VAS, significantly improved compared to the pre-treatment value (p \ 0.05). Additionally, the apnea–hypopnea index (AHI), assessed by PSG, was significantly improved compared to the pre-treatment value (p \ 0.05). Based on the results from the telephone interviews analyzed 1 year after surgery, about 88 % of patients were satisfied with the outcome. This minimally invasive snoreplasty that uses absorbable suture material is an effective and simple procedure for treating snoring and mild obstructive sleep apnea.
& Dong-Joon Park [email protected] 1
Department of Otolaryngology-Head and Neck Surgery, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju, Gangwon 220-701, Republic of Korea
Keywords Snoring Obstructive sleep apnea Soft palate Uvula muscle
Introduction Simple snoring occurs in 20 % of the adult population and in 50 % of individuals age 60 years or older. Snoring is more prevalent among men, and it is related to age and obesity [1]. The prevalence rate of obstructive sleep apnea is 2–4 % in the middle-aged population [2]. Snoring and obstructive sleep apnea occur when the upper airway, including the nasal cavity, pharynx, and larynx, repetitively narrows or collapses [3]. The collapsed area can be divided into the velopharynx, oropharynx, tongue base, and epiglottis. The most commonly collapsed area is reported to be the velopharynx [4]. Surgical treatments of the soft palate include volume reduction surgery that uses radiofrequency to increase soft palate stiffness through fibrosis [5]. Recently, palatal implants were developed and have been applied to increase soft palate stiffness by reducing vibration and collapse [6]. However, side effects after surgery such as pain, inflammation, and foreign body sense persist and caused extrusion in up to 25 % of cases [6–24]. Although surgical treatment limited to the soft palate has not been perfected, this approach has been proposed to treat snoring and obstructive sleep apnea, and there are a number of studies that indicate the importance of palatal surgery. Our study is based on the principle of tissue fibrosis and increased stiffness. We designed a minimally invasive surgical procedure using absorbable sutures to minimize side effects and to achieve improvements in snoring. Our objective was to introduce this surgical method and report its clinical usefulness and possible complications.
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Eur Arch Otorhinolaryngol
Subjects and methods Subjects We conducted this study on 35 snorer and mild obstructive sleep apnea syndrome patients who underwent this minimally invasive palatal surgery. The study was conducted at one site between January 2012 and January 2013 and was reviewed and approved by the local institutional review board (YWMR-14-8-066). Informed consent was obtained from each subject. Patients who were simple snorers without apnea or hypopnea and who had mild obstructive sleep apnea syndrome (OSAS) with a 5–15 apnea–hypopnea index (AHI) were selected. We performed Mu¨ller’s maneuver and physical examinations to select patients who were thought to have palatal collapse or fluttering as the main cause of snoring and mild OSAS. We excluded patients with an AHI of 15 or higher, nasal polyps or an obvious deviated nasal septum, patients with a history of oropharyngeal surgery, and patients with other conditions that could make snoring worse, such as moderate to severe tonsillar hypertrophy. We also excluded patients who were pregnant, on psychoneurotics, or who did not have a spouse to report their snoring. Methods The surgeries were performed under anesthesia, 10 cases received local anesthesia and 25 cases received general anesthesia. For cases with local anesthesia, the patients visited the outpatient clinic to undergo a preoperative preparation, and 4 % lidocaine was sprayed on the soft palate and oropharynx. This lidocaine administration was used to anesthetize the surgical site and prevent gag reflex during the surgery. In addition, we injected xylocaine (mixture of lidocaine and epinephrine of 1:100,000) at 0.5–1 cm above the uvula, followed by consecutive injections 1.5 cm above, left, and to the right of the previous injection site. We made a minimal incision at 0.5 cm and at 1.5 cm above the uvula in the mucosa of the soft palate. The suture was started at the mucosal incision site and continued to the mid-uvula, using polyglactin 910 (VicrylÒ) #3-0 (Ethicon, Somerville, NJ), and the needle and thread were passed through the palatopharyngeus and uvula muscles. The secondary suture was started at the out-point of the needle to the tip of uvula so the suture material would not be exposed. Next, we sutured two more times from the bottom of the uvula to the first mucosal incision site in a reverse direction using the same method and finally tied the suture thread at the incision site. With the tension of the tie, the lower margin of the uvula and soft palate were elevated, and the soft palate stiffness increased (Fig. 1). The
123
Fig. 1 Operative technique. a Suturing was started at the mucosal incision site. The needle and thread were passed through palatopharyngeus and uvula muscles, and then exited the oral mucosa. ` The needle re-entered the out-point site of the needle. ´ At the lowest point of the uvula, the suture was directed superiorly using the same method. ˆ The needle re-entered the out-point site of the needle. ˜ The suture ended at the incision site and was tied to the other side of thread, and then the mucosal incision site was closed. b Crosssectional schematic design of the technique. c Immediate postoperative photograph. Snoreplasty using an absorbable suture technique immediately elevated the uvula and increased soft palate stiffness (arrow)
Eur Arch Otorhinolaryngol
surgical process under general anesthesia was the same as that under local anesthesia. Survey Epworth Sleepiness Scale (ESS) was used to assess 35 patients prior to and 3 months after the surgery to determine symptom improvements. A 10 cm Visual Analogue Scale (VAS) that reflects the seriousness of snoring was given to the spouses of the patients. We also conducted a telephone interview of the surgery patients 1 year after the procedure and asked whether or not they were satisfied with the surgery results. Postoperative polysomnography Postoperative polysomnography was performed on seven patients that consented to comparison and analysis of AHI, oxygen saturation, sleep efficiency, percentage of sleep stages 3 and 4, and percentage of rapid eye movement (REM) sleep. Statistical analysis Statistical analysis of the results was carried using SAS 9.2 Ver. (SAS Inc., Cary, NC, USA), conducting paired t tests for continuous parametric data (AHI, Lowest SaO2, Sleep efficiency, %Stage 3, 4, and %REM) and Wilcoxon signedranks test for nonparametric data (VAS and ESS). A p value \0.05 was considered significant.
Results The average age of the 35 patients was 34 years, and there were 22 male and 13 female patients. The average body mass index was 28.5 ± 5.6 SD (Table 1). The postoperative pain was minor so the patients were able to adhere to a
Table 1 Demographic characteristics of the study population n = 35 Age (years)
34.2 ± 14.17
Sex Men Women BMI, kg/m2 AHI, per hr
22 13 28.5 ± 5.6 6.63 ± 2.41
Simple snoring
9
Mild OSAS
26
BMI body mass index, AHI apnea–hypopnea index, OSAS obstructive sleep apnea syndrome
normal diet. None of the patients suffered postoperative hemorrhage or severe edema. In comparing preoperative outcomes, it was obvious that the uvula was superiorly positioned and the stiffness of the soft palate had increased 1 day after the surgery. At 3-month post-surgery, superior positioning of the uvula and soft palate stiffness slightly decreased compared to the positioning 1 day post-surgery. However, a more elevated uvula position and greater palatal stiffness were noted compared to the preoperative status (Fig. 2). It was expected that the suture material would be nearly absorbed during the 3 months of recovery. However, the superior position of the palate may have been caused by fibrosis of the surrounding tissue as the suture material was absorbed. The ESS score decreased from preoperative 7.94 ± 2.31 SD to 5.06 ± 3.01 SD postoperatively, and this was statistically significant (p \ 0.05) (Fig. 3). The VAS conducted by the spouses before and 3 months after surgery indicated improvement in snoring after surgery, with a significant average decrease from 8.74 ± 2.28 SD to 4.14 ± 1.68 SD (p \ 0.05) (Fig. 4). Postoperative polysomnography was performed on the seven patients who consented. Preoperative AHI decreased from 6.06 ± 3.40 SD to 4.66 ± 2.04 SD postoperatively, and this was statistically significant (p \ 0.05). The lowest saturation increased from 89.43 ± 1.99 SD to 90.14 ± 2.67 SD, but this was not statistically significant. REM sleep increased from a preoperative value of 16.60 ± 3.27 SD to postoperative 17.47 ± 3.26 SD, and this result was statistically significant (p \ 0.05) (Table 2). Based on a telephone interview of 35 patients 1 year after the surgery, 31 patients (88 %) were satisfied with the surgery results.
Discussion Although various methods have been applied to treat simple snoring and mild obstructive sleep apnea, the basic principle of treatment is similar to approaches for moderate to severe obstructive sleep apnea. Widening the obstructive site and restricting fluttering tissue are the most important and principal mechanisms. Surgery, implants, oral appliances, and CPAP have been applied for those purposes. Additionally, the treatment method is selected based on patient anatomy, polysomnography, and patient preference, because there are many different operative indications and implications [25]. UPPP (uvulopalatopharyngoplasty), one of the most typical surgical methods, removes some amount of oropharyngeal mucosa. However, this can cause postoperative adhesion, hemorrhage, and pain [26]. LAUP (laserassisted uvulopalatoplasty) is a method designed to address
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Fig. 3 Epworth Sleep Scale (ESS). The mean ESS score decreased from 7.94 to 5.06 (p \ 0.05)
Fig. 4 Visual Analogue Scale (VAS). The mean VAS score decreased from 8.74 to 4.14 (p \ 0.05)
Fig. 2 a Preoperative photograph. The lower third of the uvula cannot be seen. b One day after surgery. The uvula is markedly elevated. c Three months after surgery. The uvula shows superior positioning, and stiffness of the soft palate is increased compared to the preoperative status. The entire uvula is visualized
these problems but is also accompanied by postoperative edema and pain, oral dryness, persistent foreign body sense, and adhesion in the oro- and nasopharynx [27]. These symptoms are considered to be caused by excessive excision of the palate and loss of physiologic function of the uvula [28]. To address these shortcomings, palatal implants (Medtronic, Minneapolis, MN), which are advantageous because
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of the relatively simple procedure, short recovery period, and less reported pain, have been developed and implemented [6]. However, this method can produce side effects such as extrusion, postoperative pain, inflammation, foreign body sense, and uneasiness when speaking or swallowing [6–24]. The surgical method adapted in this study was designed based on the principle of increasing stiffness through fibrosis, and we adopted minimal incision and used the absorbable suture material polyglactin 910 (VicrylÒ) to minimize postoperative hemorrhage, pain, collapse, and foreign body sense. The surgical target of this method is the soft palate, which is considered desirable for patients who have low soft palatal positions or a saggy soft palate and uvula with no narrowing in the nasal cavity, oropharynx, tongue base, or epiglottis. This method was influenced by the uvula muscleshortening method [29], which is a minimal invasive surgery to treat snoring and was developed in our institute.
Eur Arch Otorhinolaryngol Table 2 Comparison between preoperative and postoperative PSG data (n = 7)
No.
Sex
Age
AHI (per/hr)
Lowest SaO2 (%)
Sleep efficiency (%)
%Stage 3, 4
%REM
Pre
Post
Pre
Post
Pre
Post
Pre
Pre
Post
Post
1
M
43
3.5*
3.3*
92
94
88.4
89.4
2.4
2.3
10.5*
11.2*
2
F
42
4.6*
4.4*
92
92
58.3
60.1
14.6
15.1
19.8*
18.7*
3
F
24
12.9*
8.6*
88
87
52.7
54.2
16.2
16.31
15.8*
16.9*
4
F
53
8.2*
6.2*
87
87
90.9
91.2
0
2.7
16.9*
17.9*
5
M
20
4.8*
3.2*
89
90
83.6
83.7
8.1
8.3
17.5*
19.2*
6
M
43
3.6*
3.4*
88
89
88.6
87.6
5.7
5.6
15.4*
16.6*
7
F
42
4.8*
3.5*
90
92
75.6
76.9
15.7
17.5
20.3*
21.8*
Pre preoperative, Post postoperative, Lowest SaO2 lowest O2 saturation, PSG polysomnography, AHI Apnea–Hypopnea index, %stage 3, 4 percentage of sleep stages 3, 4 sleep, %REM percentage of rapid eye movement (REM) sleep * Statistically significant result (p \ 0.05)
Briefly, the uvula muscle-shortening methods selectively resect the middle part of the uvula muscle and induce shortening by suturing. Such methods have been associated with fewer complications and increased patient satisfaction compared to other existing palatal surgery methods [29]. However, resectioning the uvula muscle often requires normal gland removal due to intermixing with uvula muscle. Although the function of the glandular tissue is unclear, it seems more physiologic to avoid resection of normal tissue as much as possible. With tissue preservation in mind, we designed minimally invasive snoreplasty with absorbable thread. There is a possibility for symptom recurrence if the absorbable material and fibrosis dissolve completely over time. However, this simple and reversible method can be repeated easily. Even though the procedure was performed under general anesthesia in some patients, this procedure can now be performed at the outpatient department (OPD) base. Additionally, this procedure can be performed repeatedly, whenever symptoms present, similar to Botox or Filler injection procedures in cosmetic clinics. The ESS decreased from 7.94 to 5.06, which indicated postoperative patient satisfaction. Although this result is statistically significant, the decreased was not dramatic. This could be attributable to the fact that the characteristic of the ESS survey is to examine subjective symptoms of obstructive sleep apnea and not simple snoring. The VAS used to examine subjective discomfort of the spouses in regard to partner snoring also showed significantly decreased scores. However, although postoperative satisfaction of the spouses increased, considering the average value of VAS (4.14 ± 1.68 SD), some symptoms still persisted. This was also considered to have resulted from incomplete exclusion of multi-level obstructive sleep apnea patients, which occurred in the process of selecting snoring patients that only had palatal lesions based on Mu¨ller’s maneuver and physical examinations.
In addition, patients with the lowest O2 saturation level showed minor postoperative increases, but this result was not statistically significant. This could be due to the fact that the surgical method was conducted on simple snorers and mild obstructive sleep apnea patients with minimally decreased O2 saturation, thus resulting in minor postoperative changes in the lowest O2 saturation. When we compared our results with of those of previous reports, radiofrequency-assisted palatoplasty achieved a decrease in AHI of 28–81 %, VAS of 25–62 %, and ESS of 28–60 % [30]. For palatal implants, the results were a decrease in AHI of 12–34 %, VAS of 25–66 %, and ESS of 5–43 % [31]. On average, our method decreased AHI by 23 %, VAS by 52 %, and ESS by 36 %, showing similar results to the conventional methods. Snoreplasty using absorbable thread is a relatively simple procedure compared to existing soft palate surgery approaches. This technique can be performed with local anesthesia and simple surgical tools and is reversible because it uses absorbable thread and minimal incisions. There were no complaints of foreign body sense or xerostomia. However, this study was limited because this method was applied to patients who had soft palate lesions and was not applied to multi-level obstructive sleep apnea patients. Additionally, this procedure cannot be conducted on patients who have moderate to severe obstructive sleep apnea. The postoperative follow-up period was relatively short. To address this issue, a continuous, long-term follow-up study is needed in the future. Thus, additional research should be conducted to determine exact timing for reoperation. In conclusion, this minimally invasive snoreplasty used absorbable thread and is an effective and simple procedure for treating simple snoring and mild obstructive sleep apnea patients. This procedure minimizes shortcomings of existing surgical methods, can be performed at a lower cost, and was associated with increased patient satisfaction.
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Eur Arch Otorhinolaryngol Compliance with ethical standards Funding This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (20100022048). Conflict of interest of interest.
The authors declare that they have no conflict
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