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Laser-Assisted Uvulopalatoplasty for the Management of Obstructive Sleep Apnea
Myths and Facts
Yehuda Finkelstein, MD;
Gideon Stein, MD;
Dov Ophir, MD;
Rachel Berger, BA;
Gilead Berger, MD
Arch Otolaryngol Head Neck Surg. 2002;128:429-434.
ABSTRACT
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Objective To assess medium- to long-term subjective and objective results of laser-assisted
uvulopalatoplasty (LAUP) for patients with obstructive sleep apnea.
Design A nonrandomized prospective before-after trial.
Subjects and Interventions Twenty-six patients underwent LAUP by means of vertical trenches along
either side of the uvula and reduction of the uvula.
Main Outcome Measures Subjective analysis included a preoperative and 2 postoperative evaluations
of the state of snoring: 4 weeks and a mean ± SD of 12.3 ± 9.1
months after completion of treatment. In addition, a score on 5 other sleep-related
symptoms was recorded before treatment and after 12.3 ± 9.1 months;
at that time, patients also estimated their overall satisfaction with the
procedure. Objective analysis included preoperative polysomnographic studies
that were repeated postoperatively.
Results A significant decline in snoring improvement from 88% (23/26) to 65%
(17/26) was recorded; furthermore, the state of snoring worsened from 4% (1/26)
to 12% (3/26). Reevaluation of 5 other sleep-related symptoms after completion
of LAUP uncovered a 50% improvement rate (13/26), and a 15% (4/26) worsening
rate. Overall satisfaction from the procedure was 58% (15/26). Postoperative
objective studies revealed that only 31% (8/26) of the procedures were successful,
while 31% were associated with worsening of respiratory disturbance index.
Fifty-four percent (14/26) of the patients had a sensation of pharyngeal dryness.
In addition, 1 patient developed velopharyngeal stenosis.
Conclusions The favorable subjective short-term results of LAUP deteriorated in
time. Postoperative polysomnography revealed that LAUP might lead to deterioration
of existing apnea. These findings are probably related to velopharyngeal narrowing
and progressive palatal fibrosis inflicted by the laser beam.
INTRODUCTION
LASER-ASSISTED uvulopalatoplasty (LAUP), since its introduction in 1990,1 has become a popular treatment for the management
of snoring. Gradually, the use of the procedure has been extended to treating
various degrees of obstructive sleep apnea (OSA). Several studies have examined
the efficacy of laser treatment for OSA and reported comparable results to
uvulopalatopharyngoplasty (UPPP).2-9
However, there is growing controversy over the use of LAUP for this type of
sleep-related breathing disorder. Ryan and Love10
have recently shown that a large proportion of the patients developed significant
worsening of the objective sleep parameters. The authors concluded that the
response to LAUP was varied and unpredictable, and only a few patients achieved
a satisfactory outcome. Likewise, Lauretano et al11
found that LAUP was ineffective in these patients. It was also shown that
LAUP was associated with a considerable number of subjective delayed failures
as well as objective aggravation of sleep parameters (ie, de novo OSA) in
formerly nonapneic patients who snored.12-15
The present study forms part of a comprehensive research project on
the late anatomic, histopathologic, and clinical results of LAUP15-17
and includes a combination of subjective and objective measures to evaluate
the short- and medium- to long-term results of the procedure for patients
with OSA. Special emphasis was placed on (1) the durability of the subjective
results over time, and (2) the postoperative objective outcome of the procedure.
PATIENTS, MATERIALS, AND METHODS
The study population consisted of 26 patients who suffered from bothersome
snoring and various degrees of OSA and completed LAUP treatment between June
1, 1994, and March 30, 1995, at the outpatient clinic of Meir Hospital, Sapir
Medical Center, Kfar Saba, Israel. All patients consented to participate in
the study after being informed of the known benefits, risks, and complications
of the procedure. Patients were generally healthy without a cleft lip or palate,
and none had undergone prior mandibular or maxillary surgery.
PREOPERATIVE EVALUATION
Patients' detailed histories and bed partners' reports relevant to upper
airway obstruction were obtained in structured interviews. As previously described,15 interviewees were asked to describe their state of
snoring and to indicate the absence (0) or existence (1) of the following
5 other sleep-related symptoms: (1) night awakening, (2) morning fatigue,
(3) daytime somnolence, (4) breathing pauses, and (5) involuntary body movements
during sleep. Questions on the first 3 symptoms were addressed to the patients,
and the remainder to their bed partners. A total score from 0 to 5 was calculated
for each patient.
All patients underwent a complete otolaryngologic examination, including
flexible fiberoptic nasopharyngoscopic examination of the nose, pharynx, and
larynx, and had nocturnal polysomnography with simultaneous electroencephalography,
electrocardiography, electromyography, and surface-electrode electro-oculography.
Airflow at the nose and mouth was monitored with thermistors, and respiratory
effort was assessed with inductive plethysmography. Oxygen saturation was
measured with continuous finger pulse oxymetry. Severity of OSA was expressed
in terms of a respiratory disturbance index (RDI), and calculated as the average
number of apneas plus hypopneas per hour of sleep. The study defined 4 grades
of RDI: (1) 0 to 5, (2) 6 to 20, (3) 21 to 40, and (4) greater than 40; accordingly,
patients were considered as nonapneic snorers, mildly obstructed, moderately
obstructed, or severely obstructed.
SURGICAL METHOD
The LAUP procedure was done in the office setting, while the patient
was in an upright sitting position. Topical anesthesia included 1.5% lidocaine
spray applied to the oropharynx and the oral cavity followed by local infiltration
of a mixture of 1% lidocaine and 0.01% adrenaline into either side of the
base of the uvula and the base of the uvula. Laser surgery was performed by
means of through-and-through, full-thickness vertical trenches measuring 1
to 2 cm on the free edge of the soft palate on either side of the uvula at
a power setting of 15 to 20 W. With the use of a SwiftLase scanner (Sharplan
Lasers Inc, Allendale, NJ) attached to the carbon dioxide laser, the core
of the uvula was vaporized from the bottom up in a "fish mouth" manner, while
the mucosa of the uvula was preserved. Eventually, the uvula was shortened
and thinned by up to 80% to 90% of its original size. Enlarged tonsils were
also ablated.18
POSTOPERATIVE EVALUATION
All patients were reexamined 4 weeks and 5 to 45 months (mean ±
SD, 12.3 ± 9.1 months) after completion of the last laser treatment
(Table 1). On both occasions,
they were asked to compare current snoring to its preoperative state and to
answer whether it (1) was abolished or markedly reduced, (2) remained the
same, or (3) had worsened. In addition, the 5 other sleep-related symptoms
were assessed at the end of the follow-up period, and a total score from 0
to 5 was calculated for each patient. Possible variations between the preoperative
and postoperative scores indicated whether patients (1) improved, (2) remained
unchanged, or (3) worsened. Patients were also asked to estimate their overall
satisfaction with the procedure with a yes-no answer. Polysomnography was
repeated at the last follow-up visit at the same sleep laboratory with the
use of previously determined criteria for evaluation.
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Table 1. Anthropometry of the Study Population*
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DEFINITION OF TREATMENT EFFECTIVENESS
There is a lack of standard guidelines to assess the outcome of LAUP
for the management of OSA. Therefore, evaluation was based on commonly accepted
definitions found in the literature.6, 10, 19
We considered surgery successful when patients had a greater than 50% reduction
of their postoperative RDI compared with the preoperative value, or when it
dropped below 20 events per hour (an RDI above which OSA may be associated
with significantly increased morbidity and mortality). We considered surgery
unsuccessful when (1) postoperative RDI was reduced by less than 50% from
the preoperative value, (2) postoperative RDI remained unchanged, or (3) postoperative
RDI values worsened.
STATISTICAL ANALYSIS
Measurements were expressed as mean ± SD. Comparisons were made
by the paired t test and the McNemar test. Probability
values lower than .05 were considered significant.
RESULTS
There were 21 men and 5 women ranging in age from 22 to 71 years (mean
± SD age, 53 ± 10.2 years). Their preoperative mean body mass
index (BMI) was 28 ± 2.9 kg/m2. Assessment of BMI levels
at the end of the follow-up period revealed no significant change 27.6 ±
2.9 kg/m2 (P = .13). Treatments were carried
out in 1 to 3 sessions (mean number of sessions, 1.5 ± 0.7) (Table 1). The interval between sessions
was about 6 weeks.
SUBJECTIVE ASSESSMENT
Table 2 lists comparisons
for the changes in the state of snoring and the changes between the preoperative
and postoperative scores of each patient in 5 other sleep-related symptoms.
During the interval between follow-up visits, improvement in snoring declined
from 88% (23/26) to 65% (17/26), and worsening in snoring increased from 4%
(1/26) to 12% (3/26). Statistical analysis confirmed that the deterioration
in the state of snoring during the time lapse between the follow-up visits
was statistically significant (P = .02). Examination
of the 5 other sleep-related symptoms at the final follow-up visit revealed
that only 13 (50%) of 26 patients had improvement of symptoms, whereas 4 (15%)
of 26 reported aggravation of symptoms. An assessment of patients' overall
satisfaction from LAUP, which was also done the last follow-up visit, established
that 15 (58%) of the patients were satisfied, while the remaining 11 (42%)
were dissatisfied and reluctant to go through the procedure again.
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Table 2. Subjective Results of Laser-Assisted Uvulopalatoplasty
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OBJECTIVE ANALYSIS
Table 3 lists comparisons
for the objective findings recorded before treatment and at the conclusion
of the follow-up. The difference between the mean preoperative and postoperative
RDIs of the whole group was not statistically significant (29.6 ± 21.6
vs 25 ± 18.8, respectively) (P = .12). Only
8 patients (31%) had a successful laser surgery, whereas 18 patients had an
unsuccessful surgery. Of the latter, 7 (26%) had an insufficient reduction
of RDI levels (ie, RDI reduced <50% from preoperative value), 3 (12%) had
no change in their preoperative RDI values, and 8 (31%) had a worsening of
postoperative RDI values. In patients 7, 9, 23, and 25, worsening was detrimental
enough to change the grade of RDI from mild to moderate OSA in 2 patients,
from mild to severe OSA in 1, and from moderate to severe OSA in 1. In patients
7 and 9, the RDI worsening was greater than 100% from the preoperative value.
Preoperative and postoperative mean lowest oxygen saturation levels were not
significantly different (85.4% ± 8.5% vs 87.3% ± 7.9%, respectively)
(P = .28). Nevertheless, patient 25 had a change
of preoperative lowest oxygen saturation from 76% to 60%, a deleterious lowering
consistent with the shift from mild to moderate OSA.
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Table 3. Objective Results of Laser-Assisted Uvulopalatoplasty*
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COMPLICATIONS AND ADVERSE EFFECTS
There were no life-threatening complications, including postoperative
airway obstruction or hemorrhage. The most common adverse effect of LAUP was
pain that lasted up to 20 days postoperatively (mean ± SD duration,
9.8 ± 4.1 days) and was severe enough to keep patients away from work
for 7.2 ± 4.2 days. At the end of the follow-up visit, 14 patients
(54%) complained of persisting throat dryness or itching. Patient 13, who
underwent 3 successive LAUP sessions, developed velopharyngeal stenosis, and
after 22 months underwent UPPP to relieve obstruction.
COMMENT
It is commonly accepted that untreated patients with an RDI of 20 or
higher are susceptible to the perils of angina, cardiac arrhythmias, myocardial
infarction, stroke, and aggravation of congestive heart failure because of
the stress placed on the heart during sleep. In an attempt to alleviate snoring
and lessen episodes of apnea, 26 patients in the present study underwent a
series of LAUP treatments by means of vertical trenches. Initial subjective
results were encouraging, and as many as 88% (23/26) of the study population
improved their state of snoring. However, after a mean ± SD of 12.3
± 9.1 months, there was a significant deterioration in the favorable
results (improvement decreased to 65% [17/26]) and a significant aggravation
of the state of snoring (increased from 4% [1/26] to 12% [3/26] [P = .02]). Notably, several investigators have reported a similar trend
(ie, a progressive decline in the initially subjective favorite outcome) regarding
the efficacy of LAUP for nonapneic snorers.12-15
Furthermore, assessment of 5 other sleep-related symptoms at the end of the
follow-up treatment in the present study revealed a 50% success rate (13/26)
and a 15% failure rate (4/26). These discouraging findings suggest that LAUP
is associated with early favorable results, but that in the long run patients
may exhibit a decline in the subjective parameters of the procedure, a contingency
not mentioned by earlier reports owing to their short-term follow-up period.
Multiple studies have dealt with objective data regarding the effectiveness
of LAUP for the treatment of OSA. Most of the authors found that the success
rate ranged from 40% to 50%,2-11
yet the length of the follow-up period was either not specified2, 7
or lasted from a mean of 60 to 112 days.3-6,8-11
It stands to reason that differences in the follow-up period are responsible
for the divergent objective results: successful results in our study were
recorded in only 8 (31%) of 26 patients 13.2 ± 9.3 months after the
last laser treatment. In addition, there was a worsening of objective sleep
parameters in 8 patients (31%), 4 of whom also experienced a postoperative
deterioration of RDI grading. These data resemble those of Ryan and Love,10 who obtained, according to their terminology, a good
response in only a small proportion of the patients, a poor response in 34%,
and worsening in 30%. Likewise, Lauretano et al11
concluded that LAUP showed little or no benefit for OSA. Interestingly, Walker
et al,3, 8 Mickelson,4
and Mickelson and Ahuja9 recommended LAUP as
an effective treatment for OSA, although they noted an RDI deterioration in
21% to 27% of their cases.
Of interest is the source of the gap in the present series between the
subjective improvement in snoring (65%; 17/26) and the objective favorable
results (31%; 8/26). It was reported that LAUP reduced the maximum-, average-,
and low-frequency respiratory noise loudness, and increased the fundamental
frequency of the snoring sound. In addition, LAUP did not change the snoring
index (ie, number of snores per hour of sleep).20
Apparently, the considerable number of subjective favorable responses of patients
and bed partners in our study can be explained by the change in the snoring
sound quality, which becomes less annoying to the human ear after surgery.
Lauretano et al11 elaborated on the issue and
argued that LAUP may convert symptomatic snoring into "asymptomatic snoring,"
a scenario whereby episodes of obstruction continue masked and undetected.
Ryan and Love10 compared the phenomenon to
a "placebo effect." In other words, although surgery offers a newly agreeable
form of snoring, the subjective results may not correlate with the reduction
in the prevalence of snoring events or an improvement in the upper airway
patency.
It is thought that the late decline in the improvement of snoring, aggravation
of the sleep-related symptoms, and the overall failure in the objective measures
in our study is attributable to progressive fibrosis inflicted on soft palate
tissues by the thermal damage of the laser beam. Laser-assisted uvulopalatoplasty,
which is based on cutting and vaporizing palatal tissues, leaves a raw surface
that subsequently undergoes scarring. These wounds take longer to heal than
those created with a scalpel.21 The effectiveness
of surgery, therefore, should be assessed months later, when the healing process
has stabilized. Indeed, a study on the long-term histopathologic changes after
LAUP17 found that various components of the
soft palate underwent extensive changes, which increased with each additional
treatment. The loose connective tissue in the lamina propria was replaced
by diffuse fibrosis that also extended to the central layer on the expanse
of seromucous glands and muscle fibers.17 Palatal
fibrosis after LAUP was clinically encountered in 27% of the patients in the
Carenfelt study.22 These observations are complementary
to those found in another study16 that compared
the shape and dimensions of the velopharyngeal valve between UPPP and LAUP
by means of peroral measurements and photographs, nasopharyngoscopy, and cephalometry
performed at least 3 months after last laser treatment. It was ascertained
that after LAUP, the pharyngeal scar contracture occurred in the centripetal
direction and caused medial traction of the posterior tonsillar pillars or
even of the lateral pharyngeal walls. Eventually, the pharyngeal cross-sectional
area went through major anatomic changes that included narrowing of the lumen,
increased rigidity, decreased compliance, and loss of the distensibility needed
during inspiration.16 These deficiencies presumably
have deleterious effects on the respiratory dynamics and may deteriorate existing
OSA. Contrary to the these findings, Ryan and Love10
used videoendoscopic images and found at least 3 months after LAUP a significant
increase of the velopharyngeal cross-sectional area and its anteroposterior
diameter. Nevertheless, the authors also demonstrated a considerable number
of failures and aggravation of OSA objective measures that might have resulted
from the changes described earlier.
In the present study, patients experienced pain that lasted for an average
of 9.8 days and was severe enough to keep patients away from work for an average
of 7.2 days. These results are supported by the observations of Troell et
al,23 who compared postoperative pain between
various methods of palatal surgery in patients with snoring, upper airway
resistance syndrome, and mild apnea, and reported a mean of 13.8 and 14.3
days with pain after LAUP and UPPP, respectively. To ease pain, all patients
also consumed narcotic analgesics. The authors concluded that LAUP showed
little difference in the severity or duration of posttreatment pain when compared
with UPPP. Laser-assisted uvulopalatoplasty was also associated with annoying
pharyngeal dryness and discomfort in 14 (54%) of our 26 patients. Other reports
also noted that excessive dryness of the mouth and discomfort in the throat
were the most prominent postoperative complaints after LAUP.10, 15
The reason for the sensation of dryness is the destruction during LAUP of
multiple seromucous glands in the uvula and the posterior portion of the soft
palate, which provide continuous lubrication to the oropharynx and probably
to the vocal cords.24 Indeed, any surgical
intervention that diminishes the amount of glandular tissue may culminate
in pharyngeal dryness and surface irritation of the vocal cords, especially
LAUP, which is associated with a marked decrease in the amount and function
of velar glands because of extensive palatal fibrosis and glandular destruction.
A similar sensation of dryness in the throat along with speech articulation
problems were demonstrated in patients who underwent UPPP.25-27
Salas-Provance and Kuehn26 ascribed the changes
in the voice quality to pharyngeal dryness. Of special note is the development
of severe scarring resulting in velopharyngeal stenosis in one patient (4%),
who underwent 3 sessions of LAUP. This patient had later UPPP surgery to resect
excessive scar tissue and relieve obstruction. Huet et al28
evaluated the results of LAUP for snoring with an aerophonoscope (a noninvasive
method to assess palatal function) and found that 3 patients (12%) had scar
fibrosis and narrowing of the nasopharyngeal aperture. Carenfelt22
also reported that 2 patients (1%) of a similar cohort had this condition.
CONCLUSIONS
An American Sleep Disorders Association Report29
in 1994 withheld recommendation of LAUP as a suitable surgery to treat OSA,
declaring it an experimental procedure because of insufficient data. An update
for 2000 issued by the Board of Directors of the American Academy of Sleep
Medicine and based on review of the literature stated that LAUP is not recommended
for the treatment of OSA.30 A recent meta-analysis
based on new evaluations published in peer-reviewed articles also concluded
that LAUP should not be recommended for the treatment of any severity of OSA.31
Although LAUP has gained much popularity, there is lack of unequivocal
evidence that it provides a lasting remedy for OSA, a common yet potentially
life-threatening syndrome. It is important to separate the myths from the
facts; also there is a need to standardize outcome measures to evaluate the
procedure. The procedure has been lately criticized, especially with regard
to its inclination to aggravate patients' pretreatment condition. Indeed,
LAUP is not free of postoperative adverse reactions and complications. We
achieved a surgical success in only one third of our patients and found a
deterioration of existing OSA in a considerable number in addition to a late
worsening of the subjective initial results. The facts presented herein are
cause for concern and suggest that LAUP might not be an appropriate procedure
to treat OSA.
AUTHOR INFORMATION
Accepted for publication September 14, 2001.
We would like to thank Ilana Gelernter, MA, from the Statistical Laboratory
of the School of Mathematics, Tel-Aviv University, for providing statistical
consultation.
Corresponding author: Gilead Berger, MD, Department of Otolaryngology–Head
and Neck Surgery, Meir Hospital, Sapir Medical Center, Kfar Saba 44281, Israel
(e-mail: berger-g{at}zahav.net.il).
From the Palate Surgery Unit (Dr Finkelstein) and the Department of
Otolaryngology–Head and Neck Surgery, Meir Hospital, Sapir Medical Center,
Kfar Saba (Drs Finkelstein, Stein, Ophir, and Berger and Ms Berger), and the
Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv (Drs Finkelstein,
Stein, Ophir, and Berger and Ms Berger), Israel.
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