Note: our 19th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring course will be held on February 15-17, 2013, in Orlando, Florida. It is the largest course dedicated to snoring and obstructive sleep apnea, and it combines medical and surgical evaluation and treatment in an unique format. Please do not hesitate to contact me with any questions or if you might be interested in attending.
Soft palate surgery is the most common surgical treatment for obstructive sleep apnea in the United States and worldwide. For many years, the only sleep apnea procedure available was uvulopalatopharyngoplasty, also known as UPPP, but over the past 20 years a number of sleep apnea procedures (including other soft palate procedures) have been developed. A previous blog post and my main website include these procedures, but it can see like there are too many choices. This blog post concerns a question I am often asked by patients and colleagues: “How do you choose which palate procedure is best for a certain patient?”
This question has no easy answer. Of course, patients must always make the final decision on a procedure, but in developing my recommendation, I consider the following:
- Main cause of a specific patient’s snoring or sleep apnea (different patients have different causes)
- What the procedure does to open the breathing passage in the throat, also known as the mechanism of action
- Research studies and my own experience with a procedure
- Risks of the procedure
Snoring procedures: palate stiffening or limited tissue removal
I use at least six soft palate procedures to treat snoring and obstructive sleep apnea. The Pillar Procedure (shown below) and palate radiofrequency are less-invasive approaches that can be performed in the office with relatively mild pain and lower risks than other palate procedures. They both function by stiffening the soft palate, whether through implants or by a controlled cauterization that creates scar tissue, respectively. I use these to treat patients with snoring who have soft palates that are thin or of normal thickness, although the Pillar Procedure can also be used to treat mild sleep apnea in selected patients. Many surgeons advertise themselves as experts in snoring and sleep apnea surgery and offering the Pillar Procedure as a “new” cure-all for sleep apnea. The reality is that the Pillar Procedure is both not new and not effective for most patients with sleep apnea. The best study evaluating the Pillar Procedure in sleep apnea had a carefully selected group and showed a change from 25 to 22 in the average number of times per hour with blockage of breathing (apnea-hypopnea index) after the Pillar Procedure. Although this was a statistically-significant improvement, it is not a meaningful difference for patients, which is why I only use it in selected mild cases. The reason why I perform the Pillar Procedure more often is that patients who experience substantial improvement in snoring do maintain much of this benefit, more so than for palate radiofrequency, in my experience and reported studies.
The Pillar Procedure has limited benefit in those with extra soft palate tissue bulk or a long soft palate and uvula. A long soft palate may be related to muscle or “extra” mucosa (lining of the mouth) that can exist directly behind the tonsils and function almost like a sail that flaps in the breeze, creating the snoring sound. In these cases, palate stiffening has shown limited benefit by itself, which is why I can combine some focused tissue removal, generally using cautery (more controlled and less postoperative pain than a laser, at least for me) in a procedure called uvulopalatoplasty.
Sleep apnea surgery: tissue repositioning and/or removal
For patients with obstructive sleep apnea, I use three different procedures: UPPP, expansion sphincter pharyngoplasty, and lateral pharyngoplasty (now those names are a true mouthful, pun intended). I have discussed the procedure technique as well as advantages and disadvantages for each of these on previous blog posts. Compared to UPPP, the other two procedures have demonstrated better outcomes, in scientific evaluations of the highest quality: randomized trials with patients randomly receiving one procedure or the other. Many surgeons use one procedure, which is not wrong. However, I prefer to use all three procedures, choosing among them based on the factors outlined above.
The so-called “alternative” soft palate procedures (and some others that I do not perform, at least not in their purest form) involve tonsillectomy but have less tissue removal than UPPP, instead focusing on tissue repositioning. The goal is to create a more open, stable space for breathing while also reducing potential side effects. These side effects can be related to the amount of tissue removal (less with the alternative procedures) or injury to nearby structures. Because these alternative procedures are newer and technically more challenging, fewer surgeons perform them. The techniques have also undergone revisions and modifications, and the blog posts for expansion sphincter pharyngoplasty and lateral pharyngoplasty outline the enhancements I have learned from colleagues in Singapore, Italy, and Brazil.
Choosing a procedure for sleep apnea
My goal in soft palate surgery for sleep apnea is to open the space for breathing in what I call the Palate Region. My own research has shown that many patients, after previous UPPP or palate stiffening, continue to have blockage in the Palate Region, so in my mind we can and must do better than UPPP for everyone. My opinion is that UPPP offers the most tissue removal, and I use it if I think tissue bulk is the primary issue for a patient. Expansion sphincter pharyngoplasty pulls the soft palate forward and is my preference for those with a soft palate of normal thickness or if it is slightly thin, especially in cases of posterior tonsillar pillar webbing. The one limitation is that the muscle behind the tonsils (palatopharyngeus muscle) must be sufficiently thick for the repositioning of tissue that is involved. Lateral pharyngoplasty offers the most thorough treatment of the lateral pharyngeal walls, and when I examine a patient and see marked thickening of those tissues, it will encourage to select this procedure. The reality is even more complicated, as I will combine certain aspects of the multitude of procedures that have been described in the literature in a single case. Although I discuss the type of soft palate procedure I expect to perform with every patient in advance of the procedure, I also indicate that I may reconsider the specific technique once the procedure has started and, especially, once the tonsils have been removed.
The bottom line: the same procedure is not ideal for every patient with snoring or sleep apnea
Many years ago after a lecture in another country, a surgeon asked me this same question about selecting procedures. As I was reluctant to criticize what he was doing, he mentioned that he learned how to perform UPPP in his training but did not know about these other techniques. I mentioned that the results of various research studies may not apply to his patients and that he should not feel compelled to change his practices if he was getting good results. He responded that his results were not very good but that he kept doing them because that is the only option he had to offer. What was most disturbing was that he continued without learning new techniques (his English was excellent, and he had access to medical journals) or making dedicated efforts to understand which patients had better outcomes in his own practice. Albert Einstein defined insanity as “doing the same thing over and over again and expecting different results.” Although most surgeons in the United States and around the world only learn to perform UPPP, the awareness of these other procedures is much greater than in some other countries. One of the most rewarding aspects of what I do is sharing these newer techniques during lectures or in my operating room (and this blog) and conducting studies to improve the selection of procedures. Each patient is different, requiring us to have an array of options and a method to choose among them to achieve the best outcomes in the surgical treatment of snoring and sleep apnea.