One-Stage Laser-Assisted Uvulopalatoplasty
Robert I. Dickson, MD, FRCSC, and Donald R. Mintz, MD, FRCSC
Abstract
Objective: To assess the efficacy of an author-modified LAUP technique using the principles of UPPP surgery. This new one-stage method of LAUP is described in detail.
Design: A retrospective review of all one-stage LAUPs performed.
Setting: The Division of Otolaryngology, University of British Columbia, Vancouver, BC
Method: This one-stage LAUP was performed on all patients.
Main Outcome Measures: Improvement of snoring, postoperative pain, polysomnography, home oximetry, the Respiratory Disturbance Index, and the need for a second treatment.
Results: Two hundred twenty patients have undergone this more aggressive excisional approach, and only 10 needed a second treatment. A 75 to 100% improvement in snoring was noted by 83% of cases. In patients with some residual noise, 78% described only heavy breathing when lying on their back. Postoperative pain was mild (7 days) to moderate (7-10 days) in 79% of cases. Eighty-three percent of patients missed no work after treatment. Documented sleep-apnea was present in 74 people (33%), and 96% of these reported a more restful sleep with less daytime fatigue postoperatively. Ten of 14 patients (71%) with postoperative sleep studies had apneas eliminated or reduced by more than 50%. Overall patient satisfaction was 97%. A low-level laser from Europe (LLLT) has been introduced as an adjunct to help control postoperative pain. A clinical trial on its use in UPPP surgery is also described.
Uvulopalatopharyngoplasty (UPPP) is an established method of treatment for obstructive sleep-apnea. Although it is also effective in reducing or limiting snoring, it is less popular because of the associated morbidity of the surgery. Laser-assisted uvulopalatoplasty (LAUP) was developed as an office procedure to treat snoring under local anaesthesia with less postoperative pain. Unfortunately, it usually requires three to five sessions to be effective. This results in a greatly increased cost to the patient, both financially and in terms of overall pain.
One of the authors has previously reported a safe method of UPPP1 based on the anatomy of the palatal muscles (Fig. 1). It produced a success rate of 77.5% in treating sleep-apnea, one of the best reported series in the literature. We have used these anatomic principles to develop this one-stage LAUP procedure. The redundant soft palate and uvula are excised below the levator palati muscles. Figure 1 demonstrates the point of excision to include a part of the palatoglossus (anterior pillar), part of the palatopharyngeus (posterior pillar), and the lower portion of the uvular muscle. This part of the soft palate is not necessary for normal phonation or velopharyngeal closure. It is, however, the main source of vibration seen on simulated snoring using a flexible nasopharyngoscope. The uvular muscle can be observed as a vertical prominent ridge extending down the middle of the nasal surface of the palate.
Figure 1. Muscles of the palate from a posterior view with resection line outlined.
A lateral view of the palate demonstrates the ideal excision point 4 to 5 mm below the palatal dimple, which delineates the lower end of the levator palati muscles (Fig. 2). The same amount of soft-palate tissue is excised with our method of LAUP as with a traditional UPPP, leaving the levator muscles intact.
Two methods were employed to reduce the postoperative pain with this more aggressive approach. First, the local anaesthetic was mixed with triamcinolone acetonide (Kenalog 40), which serves to reduce pain and inflammation in the first few days after the procedure. Second, a low-level gallium aluminum arsenide laser (830 nm) (LLLT) was applied to the surgical area before and after the surgical excision. The cold laser is not essential for this one-stage LAUP technique, but it acts as an adjunct to control postoperative pain. Its use was based on a clinical trial of UPPP surgery patients performed by one of the authors (R.I.D.), described later in this article.
Over 400 patients have undergone this one-stage procedure in the last year. The results of treatment of the first 220 with adequate follow-up are reported here. Each patient and his or her bed partner were given a 3- to 4-month postoperative phone interview to determine the degree of snoring and symptom improvement and to get their opinion of the morbidity of the operative procedure. The bed partner was asked to classify the postoperative level of snoring.
Figure 2. Lateral view of the ideal excision point 4 to 5 mm below the dimple.
Method
This is a retrospective review of patients undergoing a one-stage LAUP procedure between April 1, 1994 and December 31, 1994. All patients were referred from primary care physicians for assessment and treatment of snoring alone or in combination with obstructive sleep-apnea (OSA).
A full history was obtained, with special attention given to symptoms associated with OSA. Some of the patients were referred directly from the respirologist, having been diagnosed with OSA using standard polysomnography.
A complex otolaryngologic examination was performed, with emphasis on nasal patency, palatal and tongue anatomy, presence of tonsils, and sensitivity of any gag reflex. Endoscopic evaluation of the nasopharynx and larynx was performed. The patient was visualized on simulated snoring, and the airway patency was assessed using the modified Mueller maneuver.
The majority of patients had no daytime fatigue or hypersomnolence and no apnea reported by their bed partners. If their tonsils were absent or atrophic, and if their gag reflex was not extreme, they were candidates for this one-stage LAUP procedure. Those who had symptoms compatible with OSA were offered sleep studies to establish that diagnosis.
In British Columbia, there is a 6- to 12-month waiting period for polysomnography, so many patients with mild apnea symptoms chose to proceed with surgery directly. Patients with large tonsils and severe gag reflexes were excluded as candidates for a local LAUP, but were offered the standard UPPP procedure.
Surgical Procedure
The patient was placed in a comfortable sitting position, and the palate was anaesthetized with topical Cetacaine spray. The palatal dimple was visualized when the patient gagged. An injection of 1% xylocaine with adrenaline, diluted 10:1 with Kenalog 40, was made 4 to 5 mm below the dimple in the midline (Fig. 3). This point usually corresponds to an imaginary curved line joining the edges of the anterior pillars on each side. Further injections were given on both sides 5 to 7 mm apart, extending down the anterior pillar area. The posterior pillar was injected inferiorly near the tongue. A total of 3 to 4 mL of local anaesthetic was used. The red injection points served as markers for the excision to be done later. We employed a low-level 70 mW cold laser, which was applied to the proximal palate for 1 minute in each of three spots prior to surgical excision. The laser produces a total of 3 joules of energy for each spot: the central palate, and the right and left superior poles. This also gives more time for the adrenaline in the local anaesthetic to produce vasoconstriction.
Figure 3. Outline of LAUP technique: A, Palate injection sites below the dimple. B, Application of cold laser preoperatively. C, Bilateral curved vertical incisions. D, Completing excision of uvula and soft palate following the injection points. E, Resection completed with 5 mm of palate remaining below the dimple.
The CO2 Sharplan laser was used in the continuous mode at 20 watts of power, always using the protective backstop. Bilateral trenches were made with some differences from the standard LAUP. These were started about the midpoint of the posterior pillar or the single pillar frequently seen in tonsillectomized patients. Instead of a vertical trench extending high up into the soft palate, as described by Kamami,2 we curved this incision toward the midline injection point 4 to 5 mm below the dimple. The patient is required to hold his or her breath during the vaporization to prevent aspiration of smoke. After the two lateral trenches are completed, the uvula is grasped with a long-toothed tissue forceps, and the laser is used to excise the lower soft palate and all of the uvula, from the patient’s left to right (for a right-handed surgeon). This requires 2 to 4 breath-holding periods by the patient. The segment of tissue removed varies from 1 to 4 cm in length (Fig. 4). At the superior margin, the specimen is at least 1 cm thick because of the prominence of the uvula muscle at this level. It is the amount of soft palate still remaining and not the amount removed that is most important. In some patients, there is a small amount of bleeding, which is controlled easily with a Cameron-Miller suction cautery. Any irregularities can be smoothed out using the SwiftLase, but the backstop is not removed. The cold laser is applied to the remaining palate for an additional 2 to 3 minutes. The final post-surgical appearance demonstrates that the same amount of tissue is removed as in our standard UPPP (Fig. 5).
Figure 4. Resected uvula and lower palate. Proximal portion is 1 to 2 cm thick. Length varies from 1 to 4 cm.
The patients are placed on antibiotics, analgesics, and anaesthetic mouthwash. They are told to expect a mild sore throat for 7 to 10 days. An increase in postoperative pain may be experienced 4 to 5 days post-surgically, when the steroid gets absorbed. Toradol is given as a separate prescription to be used at that point, if necessary. Dietary instructions include avoidance of citrus, spicy, or acidic foods for 2 weeks. The patients are seen in follow-up in 3 to 4 weeks’ time.
Figure 5. Resection completed leaving functional palate.
Cold-Laser Clinical Trial
The gallium aluminum arsenide infrared P-laser (830 nm) has been used in Europe and is being sold in Canada primarily to dentists (Fig. 6). It is noninvasive and nondestructive to tissues, but it has an anti-inflammatory and hypoanalgesic effect, along with producing increased tissue healing in animal experiments.5,6 The power source is a rechargeable battery that will provide 40 minutes of laser energy after 15 hours of recharging. This type of laser is used routinely by physiotherapists to reduce muscle pain and inflammation.
Figure 6. Gallium aluminum arsenide P-laser operates at 830-nm wave length (infrared) and 70-mW power (rechargeable).
A clinical trial was done to evaluate the pain-reducing properties of this laser on patients undergoing a UPPP alone or in combination with tonsillectomy prior to the institution of outpatient laser surgery. Between July 1, 1993 and December 31, 1993, all patients undergoing the procedure by one of the authors (R.I.D.) were treated intra-operatively with a 30-mW P-laser. It was applied for 5 minutes after local injection, 5 minutes after removal of the specimen, and an additional 5 minutes after the incision was closed. Each treatment was applied for 1 minute in five different locations: the central palate, and the superior and inferior poles on each side. This produced 2 joules of energy in each spot with each treatment. Otherwise, the patients were treated exactly the same intra-operatively and postoperatively as the comparable group of patients (control 1) performed by the same surgeon between January 1, 1992 and June 30, 1993. UPPP patients were discharged from the hospital as soon as their swallowing was adequate. Since pain is such a subjective symptom, we believe that postoperative discharge time is the most objective indicator of how the patients were progressing. In our healthcare system, there is an increasing pressure to reduce hospital stay, but these patients could not be discharged until their swallowing was adequate. As a comparative control (control 2), the hospital stay for patients of another staff surgeon performing numerous UPPPs without the cold laser was made over the same time period from July 1, 1993, to December 31, 1993.
Results
Cold-Laser Clinical Trial
The nursing staff immediately noted a reduction in the postoperative pain of patients with the cold laser.
Table 1 shows the hospital stay of all three groups. In the cold-laser group, only 2 of 24 patients stayed a second day. In the first control group, patients stayed from 1 to 4 days postoperatively, with an average stay of 1.84 days. In the second control group, the patients stayed 1 to 3 days postoperatively, with an average stay of 1.59 days. The ratio of patients undergoing UPPP alone to those undergoing UPPP with tonsillectomy was not significantly different between groups. The postoperative stay of the cold-laser-treated group was significantly
shorter than control group 1 (p <.001) and also when compared to control group 2 (p <.05).
Table 1 Cold-Laser Clinical Trial
| n | Total Hospital Days | Average Hospital Days | |
| Control Group 1 Surgeon (1/1/92 to 30/6/93) | 38 | 70 | 1.84 (p <.001) |
| Cold-Laser-Treated Group Surgeon (1/7/93 to 31/12/93) | 24 | 26 | 1.08 (p <.001) |
| Control Group 2 Surgeon (1/7/93 to 31/12/93) | 17 | 27 | 1.59 (p <.05) |
LAUP Study
Data collected from the 220 patients surveyed were subject to spreadsheet computer analysis. There was a predominance of 185 males (84%) in the series. Severe or legendary (impossible to share room) snoring was present in 88% of patients. Only 10 patients (4.5%) required a second treatment. A 75 to 100% improvement in snoring was reported by 83% of patients with one treatment (Table 2). Ninety-five percent of the patients were more than 50% better, and only 1 patient (0.5%) reported no improvement. Of the patients with some residual noise, 78% had only heavy breathing, mainly when they were lying on their back.
Table 2 Degree of Snoring Improvement
| % Gone | n | % of Patients |
| 100 | 41 | 18.6 |
| 90 | 72 | 32.7 |
| 75 | 70 | 31.8 |
| 50 | 26 | 11.8 |
| 25 | 10 | 4.5 |
| 0 | 1 | 0.5 |
Polysomnography-documented sleep-apnea was noted in 74 patients (33%), and 96% of them reported subjective improvement with their postoperative restful sleep and less daytime fatigue (Table 3). Sleep-apnea sufferers noted a markedly better sleep in 50% of cases. Postoperative sleep studies are planned for all of the 74 apneic patients. Since there is a long delay in getting the tests performed in British Columbia, only 14 have had full postoperative studies done at this time. Another three patients have had overnight home oximetry performed. Two of these had no desaturation; the other case has been booked for a full study. The 14 patients undergoing postoperative polysomnography were analyzed. Ten patients (71%) were successful responders to LAUP, with six cured of apneas and four with their apnea index reduced by more than 50%. In the same group, six had their Respiratory Disturbance Index (RDI) reduced by more than 50% and three others by 40%. The minimum oxygen saturation was improved in all of these 10 patients. One other patient was a partial responder. Three patients showed no significant improvement, but two of them weighed over 265 lbs.
Table 3 Qualitative Improvements: Apnea Patients
| Degree of Improvement | n | % of Patients |
| Mildly improved | 19 | 25.7 |
| Moderately improved | 72 | 20.3 |
| Markedly improved | 70 | 50.0 |
| No improvement | 26 | 4.0 |
Half of the patients (109) still had their tonsils present. In this series, the presence of atrophic tonsils did not make any difference to the degree of sleep improvement or snoring reduction. Slightly more of the patients with documented sleep-apnea had tonsils (53%). Half of the patients who required a second treatment had their tonsils present.
Twenty-two patients (10%) had a trial with continuous positive airway pressure (CPAP) prior to having LAUP done and were not satisfied with its long-term use. Patient satisfaction with the LAUP procedure was 97%. All of these patients would recommend it to a relative or friend. Only six patients (3%) stated they were not satisfied with this form of treatment, and they all reported only a 0 to 50% improvement in snoring reduction.
One patient had delayed bleeding 3 to 4 hours after surgery, which was easily controlled with a suction cautery. A single patient had delayed bleeding at 1 week, which stopped spontaneously in 5 minutes. One case had LAUP surgery performed while on therapeutic levels of anticoagulants and had no bleeding.
A few patients noted mild nasal regurgitation in the first week, similar to that experienced in routine UPPP surgery. There were no reported cases of hypernasal speech after the local anaesthetic was absorbed. Many patients had a dry feeling for 4 to 6 weeks, the length of time it takes for complete re-epithelialization to occur. One individual, who lived at a distance, had a secondary infection reported by her local doctor at 1 week; this responded rapidly to antibiotic therapy.
Most wounds healed in a reverse-U shape identical in appearance to those patients who have undergone the traditional UPPP surgery (Fig. 7). In the patients who required a second treatment, the cicatrization produced a reversed V-shaped (steeple) scar with lateral closure. In these cases, the laser was used to square off the palate, taking only a small amount in the midline but removing more laterally. When this was performed, the tight area was observed to release like an elastic band with the laser incision. Care was taken to remain below the dimple when excising the tissue with secondary treatment.
Figure 7. Three-month post-LAUP appearance of the palate similar to UPPP.
Discussion
Snoring is an obnoxious symptom that can have a profound effect on any relationship. Until recently, it was believed to be incurable without a risk to normal palate function. With the development of the UPPP operation for the treatment of sleep-apnea, it became apparent that the more redundant portion of the soft palate and uvula could be sacrificed without altering normal speech and swallowing. Although many patients with severe fatigue and apnea symptoms are willing to undergo the UPPP operation, those with pure snoring are usually unwilling.
The introduction of the LAUP by Kamami2 seemed like a good alternative for the pure snorer who wanted a less painful procedure to eliminate or reduce snoring. Since its introduction in North America, there has been a tremendous amount of media attention for this new procedure, because such a large portion of the population suffers from significant snoring. Laser companies sponsored courses throughout North America teaching the technique to advance their commercial interests. The major disadvantage of the LAUP is the multiple number of treatment sessions required to shorten, elevate, and stiffen the palate, resulting in more overall morbidity and financial cost to the patient.
The American Sleep Disorder Association3 has just reported their parameters for the use of LAUP based on a worldwide literature search. The Association believes that standard LAUP is not indicated in the treatment of sleep-related breathing disorders, including OSA. Furthermore, this group states that all patients with severe snoring should undergo sleep studies prior to LAUP to ensure that OSA is not missed once the snoring has been alleviated. They are careful to differentiate between LAUP and UPPP, which is an established form of treatment for OSA. Our method of LAUP produces a postoperative picture indistinguishable from that of UPPP patients (Fig.7). The technique outlined in this article combines the advantages of UPPP surgery removing significant tissue, with the greatly reduced morbidity seen with standard LAUP. The LAUP is not indicated in patients with marked tonsil hypertrophy, because they require a
tonsillectomy to increase the width of the oropharynx.
Postoperative sleep studies will be performed on all of the remaining sleep-apnea patients. Preliminary results show an equal effectiveness to standard UPPP patients when the patients are selected appropriately.
Kamami is now advocating LAUP for treatment of sleep-apnea patients In a recent paper,4 he reports successful reduction of the Respiratory Disturbance Index by more than 50% in 55 of 63 patients (87% success). The average number of treatments required was four. This is a higher success rate than ever reported in the literature for surgical correction of sleep-apnea. He makes no mention of how the patients were selected for surgery. Kamami also states that he has modified his original LAUP technique in some cases to perform it in a single step. He extends the two vertical trenches up to the function of the hard and soft palate. The uvula is then removed with a resection at its base, which forms a new smaller uvula, because of the deep vertical trenches. He does not document any serious complications, but the concern would be the complete bilateral transection of the levator palati muscles with the deep vertical incisions. Five OSA patients have now been cured with his single-stage technique.
We believe that the preserved uvula in the standard LAUP technique is scarred and not functional or necessary. On endoscopic nasopharyngeal examination with simulated snoring, it is obvious that the vibrating central uvula muscle is the cause of most loud snoring. After the uvula and lower soft palate are excised, the remaining central palate at the incision is about 1 cm thick. With healing and scarring, this narrows down to a few millimetres as the proximal uvula muscle atrophies. The palate still elevates normally, because the levator palati muscles have been preserved.
There has been a great deal of controversy over the effects of low-level laser (LLLT) on wound healing and pain control. There are multiple animal experiments showing the benefits of LLLT on wound healing.5,6 There is wider clinical use of LLLT in dentistry, where studies have shown its benefit in reducing tooth hypersensitivity,7 in repairing damaged inferior alveolar mental and lingual nerves,8 and in controlling post-dental-procedure pain, usually caused by a hyperemic pulp.9
Low-level lasers are used routinely by physiotherapists who report therapeutic effectiveness on muscle pain.10
A recent double-blind pilot study on the use of LLLT for treatment of post-cholecystectomy pain using a P-laser identical to the one used in the study showed encouraging results.11
In two articles from Japan, the use of the gallium aluminum arsenide (830 nm) P-laser has shown itself effective in controlling various types of neurologic pain.12,13
There are no reports on the use of cold lasers in otolaryngology. More double-blind clinical trials are needed to determine the effectiveness and clinical indications of low-level laser therapy.
Conclusions
A one-stage LAUP procedure for the treatment of snoring, based on the palatal musculature, has been detailed. Eighty-three percent of 220 patients had a 75 to 100% elimination of their snoring. Only six patients (4.5%) required a second treatment. Postoperative pain was mild to moderate in 79% of cases, and 83% of the patients missed no work.
One third of the patients had documented sleep apnea, and 95% of them had clinically significant improvement in their sleeping and daytime fatigue. To date, 14 postoperative polysomnograms have been performed, and 10 of these patients (71%) were responders. However, no final statement can be made about any equal effectiveness with UPPP surgery for the treatment of sleep-apnea until more post-surgical sleep studies are obtained.
The presence of small tonsils did not affect outcome. Complications were extremely minimal, and the overall patient satisfaction was 97%.
A low-level infrared P-laser was introduced as an adjunct to reduce pain. A clinical trial on its effectiveness on UPPP patients was presented.
Acknowledgements
The authors thank Pamela Dickson, Christopher Thorpe, and Rosemary Schellenberg for their help in the preparation of this manuscript.
References
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11. Moore KC, Hira N, Broome IJ, Cruikshank JA. The effect of intra-red dioxide laser irradiation on the duration and severity of postoperative pain: a double blind trial. Laser Ther 1992; 4:145-149.
12. Shiroto C. Retrospective study of diode laser therapy for pain attenuation in 3635 patients: detailed analysis by questionnaire. Laser Ther 1989; 1:41-47.
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Notes
Received 9/12/95. Received revised 12/18/95. Accepted for publication 1/3/96.
Robert I. Dickson and Donald R. Mintz: Department of Surgery, Division of Otolaryngology,
University of British Columbia Faculty of Medicine, Vancouver, British Columbia.
Presented at the annual Meeting of the American Laryngological, Rhinological and Otological Society, Inc., Palm Desert, California, May 1995.
Address reprint requests to: Dr. Robert I. Dickson, 212-888 West 8th Avenue, Vancouver, BC V5Z 3Y1.
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