Surgeries for Palate Reduction Found to Have Few Complications

Obstructive sleep apnea syndrome (OSAS) has received significant attention from the public and medical community, not only for its association with cardiovascular disease, but its impact on the quality of life of the millions of young and old diagnosed with this disorder.

For some, weight loss and a decreased consumption of alcohol alleviate the severity of the disorder. However, most must face the only viable treatment option of surgery -- and they are reluctant to do so because of a concern for complications during and after the surgical procedures. Now a team of otolaryngologists from Brazil have examined the skeletal surgeries carried out in treating primary snoring and mild and moderate OSAS. They focused on procedures limited to the palate, lower tongue and skeletal surgeries, and areas of the upper airway most receptive for treatment.

The authors of "Complications in Sleep Obstructive Apnea Surgeries" are Jose Antonio Pinto MD (Director), Nelson E P Colombini MD, and Gustavo J Faller MD, all from the Center of Otolaryngology and Head and Neck Surgery of Sao Paulo, San Paulo, Brazil. Their findings were presented at the Annual Meeting and OTO EXPO of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, held September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: The patients in the study were diagnosed with primary snoring or OSAS and had undergone surgical treatment between January 1996 and December 2001, a total of 785 cases and 945 procedures. The procedures were: 243 uvulopalatopharyngoplasties, 178 uvulopalatopharyngoplasties with laser CO2 (LAUP), 148 somnoplasties of the palate, 80 midline glossectomies, 45 somnoplasties of tongue base, 65 thyrohyoidopexy, 65 Osteotomies Le Fort I, 72 mandibular sagittal osteotomies, 39 mentoplasties with genioglossal advancement, and ten piriformeoplasties. Complications were then assessed and corrected for additional disease prevention according to accepted procedures found in the literature.

Results: Complications most commonly observed were the following: hemorrhage (17), hypoesthesia of lower alveolar nerve (17), difficulty of endotraqueal intubation (3), loss of fixation of skeletal procedures (3), locorregional edema with obstruction of upper-airway (UA), infection (2), and a single case of loss of occlusal relation. The complications were solved through surgical, clinical or associated procedures. There were no deaths in the series, however, a blood transfusion was necessary in two cases and tracheotomy in 12 cases. An assessment of the most widely performed procedures follows:

The uvulopalatopharyngoplasty (UPPP) was the first procedure specifically designed to correct palatal alterations in patients with OSAS. This requires maximizing shrinking of the soft palate in its lateral angles, siding and pushing back the hind pillars, thus augmenting the lateral dimension of the oral pharynx and preserving the musculature of the median line. It is prescribed for patients with a lowered and diaphragmatic palate, with enlarged tonsils, redundancy and flaccid posterior pillars, together with a long and thick uvula. The most common complications include nasal obstruction, thick post nasal drip, pain, sensation of a drying pharynx, hoarseness, and snoring. The initial symptoms begin between four to five weeks after the procedure; needed corrections should be made approximately six months after the initial procedure, and can be surgical, through zetaplasties, rotation of the oral or pharyngeal flaps, free skin or mucous grafts, CO2 laser or infiltrations of steroids.

The LAUP (laser-assisted uvulopalatoplasty), since 1990 is used for primary snoring and mild and moderate OSAS. Its application is limited to palatal alterations, mainly the thin palate, lowered with elongated uvula and small tonsils. It can also be used with other techniques. The procedure is performed in the majority of cases in the doctor's office under local anesthesia. Most of the mentioned complications are temporary, and the researchers found none required hospitalization. A hemorrhage during the procedure was found to be one of the most common complication. In post-operative infectious complications, candidiasis (a yeast-like fungus infection) was the most common. Another potential complication was the alteration in the volume of the middle ear and its pressure by partial section of the palate muscles responsible for the opening and closing of the Eustachian tube. This finding was not statistically proven.

Somnoplasty of the palate is a recent technique that uses radiofrequency in low voltage, applied by an electrode in a needle inserted into the palate. Thermal properties and energy liberated are controlled through a feedback mechanism. Its effect is the volumetric reduction and the increase in tissue tension. It can be performed on the soft palate, turbinates, base of the tongue and recently on the palatine tonsils. Its application on the soft palate is restricted to cases of primary snoring, mild and moderate apneas. Normally, three applications in three areas are made at intervals of approximately four weeks. The incidence of intense nauseous reflex that hinders the procedure was found in around five percent of 148 cases performed by the researchers. Pain was present but not severe in those receiving the procedure.

Conclusion: Most physicians justifiably will explore all treatment options before recommending surgery. The research findings in this study suggest that primary care or family physicians should not be reticent in recommending a surgical solution to obstructive sleep apnea syndrome due to concerns of complications. In Brazil, the complications and their incidence did not differ from the non-debilitating ones found in the medical literature. Special attention, however, must be given to patients suffering from moderate or severe apnea, whose morbidity is considerably augmented in relation to other patients, except for those with risk increased by systemic pathologies. An adequate surgical planning, associated with care and attention regarding maintenance of a permeable airway, are necessary for these patients to avoid severe complications.

Learn more about snoring and obstructive sleep apnea at http://www.entnet.org/healthinfo/snoring/snoring.cfm.