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Objectives: To assess the influence of different soft palate surgeries for obstructive sleep apnea (OSA) on eustachian tube function symptoms, considering various potential factors., Methods: A prospective, cohort study was conducted on patients who underwent isolated palatal surgeries for OSA at a single academic medical center between 2017 and 2022. Eustachian Tube Dysfunction Questionnaire (ETDQ-7) were assessed at baseline, 1-month, 2-month, and 3-month time points. Patients with retropalatal obstruction underwent tailored surgeries: anterior palatoplasty (AP), expansion sphincter palatoplasty (ESP), or barbed palatoplasty (BP). Baseline OSA severity between baseline and follow-up time points were also examined., Results: In this study, 96 patients with OSA were enrolled and allocated to three surgical groups: AP (n = 30), ESP (n = 32), and BP (n = 34). The mean age was 44.3 ± 10.2 years, with 86% male participants. No significant differences were found between the groups in terms of age, sex, and BMI. A two-way repeated measures ANOVA revealed a significant main effect of time on ETDQ-7 scores (p < 0.001), but no significant main effect of groups (p = 0.109) or interaction between time and groups (p = 0.082). Subgroup analysis showed a significant interaction for the 3-month change in ETDQ-7 scores by OSA severity (p = 0.046). In post hoc analysis, the BP group exhibited a higher mean ETDQ-7 score compared with the AP group at the 3-month follow-up., Conclusion: This study highlights the importance of considering individual patient factors, such as OSA severity and eustachian tube function symptoms, when selecting the most appropriate surgical treatment to optimize outcomes., Level of Evidence: 4 Laryngoscope, 134:2471-2477, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes., Methods: Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h., Results: Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m 2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI., Conclusion: Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates., Level of Evidence: 3 Laryngoscope, 134:981-986, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique., Study Design: Retrospective cohort., Methods: A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected., Results: Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p ˂ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI., Conclusions: The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes., Level of Evidence: 4 Laryngoscope, 133:822-829, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To investigate whether modified uvulopalatopharyngoplasty (UPPP) for treatment of obstructive sleep apnea (OSA) remained effective after 8 years., Methods: Prospective intervention study. Sixty-five patients with OSA were offered re-evaluation with polysomnography and the Epworth Sleepiness Scale (ESS) 8 years after UPPP. Results were compared with baseline and with a previous 2-year follow-up. Baseline predictors were analyzed with regression analyses., Results: The dropout rate at the 8-year follow-up was 28%. The mean decrease in apnea-hypopnea index (AHI) between baseline and the 8-year follow-up was significant, 14.0 events/hour (from 52.9 to 38.9), 27% (P < .001). The mean increase in AHI between the 2-year and the 8-year follow-up was significant, 14.7 events/hour (from 24.2 to 38.9), 61% (P < .0001). Overweight at baseline predicted an AHI at the 8-year follow-up that was 22.9 events higher compared to patients with normal weight (P = .015). An increase in body mass index (BMI) of 1 kg/m 2 between baseline and the 8-year follow-up predicted a mean AHI increase of 3.8 events/hour (P = .015). The median decrease in ESS between baseline and the 8-year follow-up was significant, 7 (from 13.0 to 6.0), 54% (P < .0001). The median increase in ESS between the 2-year and the 8-year follow-up was not significant, 1.0 (from 5.0 to 6.0), 20%., Conclusion: Modified UPPP was effective as a long-term treatment for OSA in selected patients, although the effect on AHI decreased over time. Daytime sleepiness remained improved even in the long term. High BMI at baseline and an increase in BMI predicted a reduced long-term respiratory outcome., Level of Evidence: 3 Laryngoscope, 131:E307-E313, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Postoperative pain for tonsillectomy with or without adenoidectomy or uvulopalatopharyngoplasty (UPPP) can be severe. Ketorolac is a nonsteroidal anti-inflammatory drug that can be administered for analgesia in these patients. In the literature, ketorolac has been associated with an increased risk of hemorrhage after tonsillectomy with or without adenoidectomy. Many other surgical fields have successfully utilized this medicine for postoperative pain control without increased incidence of hemorrhage. The goal of this study was to analyze the effectiveness of ketorolac after tonsillectomy with or without adenoidectomy or UPPP in adults on postoperative hemorrhage rates., Methods: Adult patients older than 18 years of age who underwent tonsillectomy with or without adenoidectomy and UPPP between 2013 and 2018 were assessed to determine hemorrhage rates. Hemorrhage rates were assessed based on patients presenting to the emergency department with complaint of hemorrhage., Results: There was no significant difference between groups in the postoperative hemorrhage rates (P = .331) or the method of hemorrhage control., Conclusion: Ketorolac did not increase postoperative hemorrhage rates in patients posttonsillectomy with or without adenoidectomy or UPPP., Level of Evidence: 4 Laryngoscope, 130:876-879, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: To compare the functional outcomes and complication rates in patients who underwent expansion sphincter pharyngoplasty with anterior palatoplasty (ESPwAP) versus barbed pharyngoplasty (BP)., Study Design: Retrospective cohort study., Methods: A medical database was used to retrieve the records of 129 patients who had an isolated palatoplasty surgery between January 2014 and July 2018. Patients who had mild or moderate obstructive sleep apnea without a history of revision surgery and underwent ESPwAP or BP in addition to traditional tonsillectomy were included in the study. Pre- and postoperative polysomnography and Epworth Sleepiness Scale (ESS) was evaluated in the patients who completed at least a 6-month follow-up period., Results: Forty-five and 53 patients met the inclusion, and were comprised of BP and ESPwAP groups, respectively. ESPwAP and BP significantly improved mean apnea hypopnea index (AHI) from 28.5 to 9.1 (P = .000) and 25.9 to 7.4 (P = .000), respectively. No significant statistical difference was found between the mean AHI scores of two groups. Selecting a threshold of a 50% reduction in AHI and AHI less than 20 events/h, success rates were 86.6% in BP group and 84.9% in ESPwAP group., Conclusions: Our study showed that both types of surgeries are effective with comparable results. The BP technique may be preferred when possible to avoid soft tissue excision and seems to be a less invasive procedure with a similar success rate when compared to ESPwAP., Level of Evidence: 4 Laryngoscope, 130:E275-E279, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To evaluate the association between upper airway surgery and changes of cardiological metabolic biomarkers and the overall cardiovascular risk in obstructive sleep apnea (OSA), and to define factors associated with better cardiovascular outcomes., Methods: A total of 161 patients with newly diagnosed OSA who underwent classical or modified uvulopalatopharyngoplasty with or without genioglossus advancement and hyoid suspension were included. The pre- and postoperative (at least 6 months later) assessments, including polysomnography, measurement of glucose and lipids, blood pressure, and overall cardiovascular risk (as estimated by Framingham Risk Scores), were compared. We accounted for multiple comparisons with the use of the Benjamini-Hochberg correction., Results: The mean follow-up time was 2.5 ± 1.9 years. The apnea hypopnea index decreased significantly in the entire cohort (mean changes with 95% confidence intervals were [-25.3 (-29.5, -21.0) events/hour, P < 0.001]. We also noted decreases in the age-adjusted Framingham Risk Scores [-2.5% (-4.0%, -1.0%), P < 0.001] as well as single cardiometabolic biomarkers, including glucose [-0.50 (-0.70, -0.30) mmol/L, P < 0.001], total cholesterol [-0.46 (-0.65, -0.28) mmol/L, P < 0.001], triglycerides [-0.56, (-0.99, -0.14) mmol/L, P = 0.014], low-density lipoprotein cholesterol [-0.27, (-0.43, -0.11) mmol/L, P = 0.002], apolipoprotein B [-0.10 (-0.14, -0.07) g/L, P < 0.001], systolic blood pressure [-3.58 (-6.02, -1.14) mmHg, P = 0.007], and diastolic blood pressure [-3.25 (-5.47, -1.02) mmHg, P = 0.008] after surgery. Patients with preoperative metabolic abnormalities exhibited better postoperative risk profiles changes (P < 0.001). In addition, associations were found between Δapolipoprotein B, Δsystolic blood pressure, and improvements in nocturnal oxygen level after surgery., Conclusion: OSA-related upper airway surgery was associated with improvements in cardiological metabolic biomarker levels and the overall cardiovascular risk, especially in patients with both OSA and metabolic disorders. The changes in biomarker levels may be associated with improved oxygen saturation after surgery., Level of Evidence: 4 Laryngoscope, 130:818-824, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: We have previously shown that modified uvulopalatopharyngoplasty (UPPP) is effective to treat obstructive sleep apnea (OSA) and that the effect is stable after 24 months. This continuous report includes questionnaires and phone interviews., Study Design: Prospective intervention study., Methods: Sixty-five patients with apnea-hypopnea index (AHI) score ≥ 15, body mass index <36 kg/m 2 , and Epworth Sleepiness Scale (ESS) score ≥ 8 underwent modified UPPP after failing nonsurgical treatment. The results from a patient questionnaire at 6 and 24 months after surgery were correlated with age, body mass index, and ESS and AHI scores. Patients reporting side effects and/or regretting the surgery after 24 months were selected for phone interviews 9 years after surgery., Results: The response rate was 80% and 74% at the 6- and 24-month follow-ups, respectively. Of those who responded to the questionnaire, 96% and 83% were satisfied after 6 and 24 months, respectively; 98% and 92% recommended the surgery. Side effects (globus, mucus, and voice and swallowing disorders) occurred in 38% and 31%, respectively. Dissatisfaction correlated significantly with high postoperative AHI and ESS scores, but not with occurrence of side effects. Younger subjects had a higher rate of recommendation and lower rate of side effects than did older subjects. Phone interviews after 9 years were responded to by 14 of 16 selected patients, and the responders reported minor or no side effects., Conclusions: The vast majority of the OSA patients were satisfied 24 months after surgery, even though a third of them were experiencing side effects. Younger patients had fewer side effects than did older patients. Patients with better OSA outcomes were also more satisfied. After 9 years the side effects were no longer problematic., Level of Evidence: 2b Laryngoscope, 130:263-268, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To investigate the increase in the incidence of depression in patients with obstructive sleep apnea (OSA) and its preventability by uvulopalatopharyngoplasty (UPPP)., Methods: In this retrospective cohort study, data from the Korea National Health Insurance Corporation were analyzed. A total of 160,840 participants (age ≥ 20 years) who were newly diagnosed with OSA between 2007 and 2014 were included. The participants were classified into a group that underwent UPPP (UPPP group, n = 19,773) and a group that did not undergo surgical treatment (no surgery group, n = 141,067). Propensity score matching by age and sex was used to select the control group of 804,200 subjects. The mean follow-up duration was 4.6 ± 2.3 years. The primary endpoint was newly diagnosed depression., Results: The incidence of depression was higher in patients with OSA than in controls (hazard ratio [HR]: 1.678, 95% confidence interval [CI]: 1.650-1.706). The UPPP group was still at a higher risk of depression than was the control group (HR: 1.535, 95% CI: 1.463-1.610), but the HR was statistically lower than that in the no surgery group (HR: 1.694, 95% CI: 1.665-1.724)., Conclusion: OSA increases the incidence of depression, which may be prevented to some extent by UPPP., Level of Evidence: 2b Laryngoscope, 129:1005-1009, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Our previous randomized controlled trial of patients with obstructive sleep apnea syndrome (OSAS) showed that modified uvulopalatopharyngoplasty (UPPP), including tonsillectomy, significantly improved nocturnal respiration, daytime sleepiness, and quality of life in the intervention group compared to controls who had delayed surgery after 6 months. This is the continuous report with the 6- and 24-month postoperative results., Study Design: Single-center prospective cohort study., Methods: Sixty-five patients with apnea-hypopnea index (AHI) ≥ 15, body mass index (BMI) < 36, Epworth Sleepiness Scale (ESS) ≥ 8, and Friedman stage I or II underwent UPPP after failing nonsurgical treatment. The results from polysomnography and ESS at 6 and 24 months were compared to baseline., Results: Eight percent and 20% dropped out from the 6- and 24-month follow-ups, respectively. The AHI value decreased significantly from mean (standard deviation) 52.9 (20.5) at baseline to 23.6 (20.2) after 6 months, and to 24.1 (20.9) after 24 months (P < 0.001). Patients with tonsil size 2, and 3 to 4, had significant reductions in the AHI after both follow-ups. The median ESS score decreased significantly from 13 (range 8-21) to 6.5 (1-18) after 6 months, and to 5 (2-17) after 24 months (P < 0.001). The BMI remained unchanged. There were significant modest correlations for the reductions in AHI and ESS after 24 months., Conclusion: Modified UPPP was effective in improving nocturnal respiration and daytime sleepiness in OSAS patients at both 6- and 24-month follow-up. Patients with tonsil size 2, and 3 to 4, benefitted similarly from surgery with improved respiration., Level of Evidence: 2b. Laryngoscope, 128:1238-1244, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the feasibility of transoral endoscopic nasopharyngectomy without division of the soft plate using a flexible, next-generation robotic surgical system., Study Design: Preclinical anatomic study using four human cadavers., Methods: Transoral resection of the nasopharyngeal wall with en-bloc resection of the cartilaginous Eustachian tube and dissection of the parapharyngeal fat space., Results: The first flexible robotic surgical system has recently been described. We performed a series of laboratory experiments to determine whether this flexible system could be used to perform transoral robotic nasopharyngectomy. This novel system allowed docking of the patient-side cart at the side of the operating table. The cannula tip was placed approximately 12 cm from the edge of the retractor pointing superiorly toward the nasopharynx (NP). Retraction of the soft palate anteriorly and tonsillar pillars laterally with stay sutures expanded the velopharyngeal inlet, providing adequate space to deploy all four instruments (three surgical instruments and a camera) into the NP for dissection. All instruments could be deployed into the NP, without collision or restriction of joint movement in this cadaver model. Using this position and docking location, the new flexible surgical robot provided sufficient access, reach, and visualization to complete robotic nasopharyngectomy with en-bloc resection of the cartilaginous Eustachian tube., Conclusion: This feasibility study showed that transoral endoscopic nasopharyngectomy could be performed without compromising the integrity of the soft palate using a novel flexible robotic surgical system., Level of Evidence: N/A. Laryngoscope, 126:2257-2262, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Evaluate the effect of topical application of autologous platelet-rich plasma (PRP) in primary repair of complete cleft palate and then compare the result with another group of patients using the same surgical technique, without application of PRP with regard to the incidence of oronasal fistula, velopharyngeal closure, and grade of nasality., Study Design: Case control study., Methods: This study was carried on 44 children with complete cleft palate with age range from 12 to 23 months. The children were divided into two age- and gender-matched groups: All children were subjected to the same technique of V-Y pushback repair of the complete cleft palate. In group A (22 children), the PRP prepared from the patient was topically applied between the nasal and oral mucosa layer during palatoplasty, whereas in group B (22 children) the PRP was not applied., Results: All cases were recovered smoothly without problems. In group A, no oronasal fistula was reported, whereas in group B three patients (13.6%) had postoperative fistulae and two patients (9.1%) needed revision palatoplasty. At 6 months postoperative assessment, group A (with PRP application) showed significantly better grade of nasality (P = 0.024) and better endoscopic velopharyngeal closure (P = 0.016) than group B., Conclusion: Usage of autologous PRP in complete cleft palate repair is simple; effective; can decrease the incidence of oronasal fistula; and also significantly improves the grade of nasality and velopharyngeal closure, which decreases the need of further surgical intervention in cleft palate patients., Level of Evidence: 3b. Laryngoscope, 126:1524-1528, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Our previous study showed that modified uvulopalatopharyngoplasty (UPPP), including tonsillectomy, significantly improved nocturnal respiration in obstructive sleep apnea syndrome (OSAS) patients. This is a continuous study of changes in daytime sleepiness and quality of life., Study Design: Prospective randomized controlled trial (RCT), two parallel arms., Methods: Sixty-five patients with apnea-hypopnea index ≥ 15, body mass index < 36, Epworth Sleepiness Scale (ESS) ≥ 8, Friedman stage I or II, failing nonsurgical treatment. The intervention group (n = 32) underwent surgery, and the controls (n = 33) had no treatment. At baseline and the 7-month follow-up, polysomnography, questionnaires, and vigilance tests were implemented., Results: All patients answered the questionnaires, and 48 took the vigilance test. Epworth Sleepiness Scale decreased significantly in the intervention group, from a mean (standard deviation) of 12.5(3.2) to 6.8(3.9), but nonsignificantly in the control group, from 12.9(3.1) to 12.5(3.9), a significant group difference (P < 0.001). The physical and mental component score on the Short Form-36 questionnaire increased significantly in the intervention group, from a mean 47.8(8.3) to 51.2(8.8) and from 42.1(10.6) to 48.1(9.7), respectively, but with nonsignificant changes in the controls: 49.0(9.0) to 48.3(9.1) and 41.0(10.2) to 42.7(11.5), significant group differences (P = 0.007, P = 0.031), respectively. The sleep latency/vigilance test showed a significant mean increase in the intervention group of 7(12.4) minutes and a decrease in the controls of 2.2(10.6), a significant group difference (P = 0.011). There were significant correlations between changes in subjective outcomes and nocturnal respiration., Conclusion: This RCT shows that modified UPPP was effective in improving daytime sleepiness and quality of life in OSAS patients. It strengthens the body of evidence on the potential effect of surgery offered to selected patients., Level of Evidence: 1b. Laryngoscope, 126:1484-1491, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Mandibular advancement devices are an alternative to continuous positive airway pressure for patients with mild or moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). The main aim of this review was to assess the effectiveness of different devices in treating OSAHS, based on polysomnographic measurements such as the apnea/hypopnea index (AHI) and oxygen saturation, and on changes in the upper airway and improvements in the most common symptoms: snoring and somnolence. Their adverse effects were also noted., Study Design: Systematic review., Methods: Following an exhaustive search in the Medline, Scopus, and Cochrane Library databases, 22 articles published in the past 10 years met the quality and inclusion criteria., Results: Using mandibular advancement devices during the hours of sleep helps to prevent snoring and excessive daytime sleepiness, reduce the AHI significantly, and bring about beneficial changes in the upper airway. Adjustable and custom-made mandibular advancement devices give better results than fixed and prefabricated appliances. Monobloc devices give rise to more adverse events, although these are generally mild and transient., Conclusions: Mandibular advancement devices increase the area of the airway. They bring the soft palate, tongue, and hyoid bone forward and activate the masseter and submental muscles, preventing closure. All these effects reduce the AHI, increase the oxygen saturation, and improve the main symptoms of OSAHS., Level of Evidence: NA., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: This study aimed to compare application of the Müller maneuver (MM) and application of drug-induced sleep endoscopy (DISE) prior to surgery, in addition to MM, to further ascertain the location of an obstruction in the upper airway and whether the location would change the surgical treatment plan in patients with retropalatal obstruction., Study Design: Prospective, clinical trial at a tertiary referral hospital., Methods: This study included 39 obstructive sleep apnea patients who were recommended for surgical treatment. Patients were randomly divided into two groups: The first group (DISE plus MM) underwent a DISE (19 patients), in addition to the planned procedure according to MM. Meanwhile, the second group (MM only) underwent surgery based only on their MM evaluation (20 patients). Patients with retrolingual-localized obstructions were excluded, whereas patients with ≥ third-degree obstructions at the retropalatal level, according to DISE and/or MM, were included in the study., Results: There was a significant improvement between pre- and postoperative polysomnography findings in both groups. However, the postoperative improvements between the groups were not statistically different. Because there was a significant change in the planned surgical procedures in the first group, there were significantly more combined surgeries followed by the DISE procedure., Conclusions: Although the DISE resulted in more changes in the surgical treatment plan and higher rate of combined treatment compared to MM, we determined that this difference did not result in a significant difference in treatment success., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To quantitatively measure volumetric changes in upper airway soft tissue structures using magnetic resonance imaging (MRI) pre- and post transoral robotic surgery for obstructive sleep apnea (OSA-TORS)., Study Design: Prospective, nonrandomized, institutional board-approved study., Methods: Apneics undergoing OSA-TORS, which included bilateral posterior hemiglossectomy with limited pharyngectomy and uvulopalatopharyngoplasty, had upper airway MRIs pre- and postoperatively. Changes (percent and absolute values) in upper airway and surrounding soft tissue volumes were calculated. We assessed whether there were significant volumetric changes and if changes correlated with apnea-hypopnea index (AHI) changes., Results: Nineteen MRIs and 18 polysomnograms were analyzed pre- and postoperation. Total airway volume increased by 19.4% (P = 0.030). Soft palate and tongue volumes decreased by 18.3% (P = 0.002) and 5.8% (P = 0.013), respectively. Retropalatal and total lateral wall volumes decreased by 49.8% (P = 0.0001) and 17.9% (P = 0.008), respectively. Changes in other structures were not significant. Eleven patients had surgical success, with a mean AHI decrease of 52.9; six were nonsuccesses with a mean AHI decrease of 4.5 (P =0.006). Decreased retropalatal lateral wall volume correlated with decreased AHI., Conclusion: Airway, tongue, soft palate, and lateral wall volumes change significantly after OSA-TORS. Changes in the volume of the lateral walls correlated with changes in AHI. Volumetric upper airway MRI may be a helpful tool to better understand reasons for surgical success., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To evaluate the effect of radiofrequency surgery of the soft palate on daytime sleepiness in snoring men with mild or no sleep apnea., Study Design: Randomized controlled trial., Methods: Thirty-five men were recruited from consecutive patients referred to the Ear, Nose, and Throat Clinic due to snoring and complaints of daytime sleepiness. The inclusion criteria were an apnea-hypopnea index (AHI) of ≤ 15, male gender, and age 18 to 65 years. Patients were randomized to either radiofrequency or sham surgery of the soft palate. All but one chose and received the option of three treatments. All patients participated in a follow-up, including an overnight sleep apnea recording and questionnaires 12 months after the last treatment. The primary outcome was daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) and other questionnaires. Secondary outcomes were effects on the AHI and subjective snoring., Results: Thirty-two of 35 patients-19 of 20 patients in the radiofrequency surgery group and 13 of 15 patients in the sham surgery group-completed the study. No differences between the two groups in relation to the ESS or AHI were found at follow-up., Conclusion: Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring, or apnea frequency in snoring men with mild or no sleep apnea 1 year after surgery., Level of Evidence: 1b. Laryngoscope 124:2422-2426, 2014., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To compare polysomnography (PSG) data after nasopharyngeal tube (NPT) insertion and uvulopalatopharyngoplasty (UPPP), and explore the possibility of predicting UPPP outcomes with NPT-PSG., Study Design: Prospective nonrandomized study., Methods: PSG was performed after NPT insertion in 73 inpatients with obstructive sleep apnea-hypopnea syndrome (OSAHS). All patients accepted UPPP surgery. PSG was repeated after 12 months of UPPP to assess curative effects. Data were then compared to correlate NPT-PSG with the efficacy of UPPP., Results: NPT insertion decreased the overall apnea-hypopnea index (AHI) and increased the lowest oxygen saturation (LaSO2 ). NPT-PSG results correlated well with surgical outcomes 12 months post-UPPP. The correlation coefficient for AHI and LaSO2 were 0.571 (P < .001) and 0.268 (P = .033), respectively. Next, enrolled patients were divided into two groups based on NPT-PSG results: group A, AHI <15 times/hr, 50 cases; group B, AHI ≥15 times/hr, 23 cases. The UPPP surgery success rates of the two groups were 86.0% and 39.1%, respectively., Conclusions: NPT-PSG data are closely correlated with UPPP efficacy and may assist in the selection of appropriate OSAHS patients for UPPP. An AHI ≥15 times/hr after NPT insertion indicates glossopharyngeal obstruction and suggests the need for appropriate intervention., Level of Evidence: 4., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To analyze and assess the perioperative risks and complications in patients receiving general anesthesia undergoing surgery for obstructive sleep apnea (OSA)., Study Design: Retrospective chart review of patients with documented OSA who underwent uvulopalatopharyngoplasty (UPPP) with or without septoplasty for OSA between January 2009 and January 2010 at a specific institution. Anesthesia, operative, clinical, and postoperative/recovery nursing records were collected and reviewed for predetermined complications and risk factors., Methods: Chart review was performed via electronic medical records, reviewing the perioperative course of 32 patients undergoing UPPP as identified by Current Procedural Terminology coding. Perioperative, clinical, and anesthetic records were reviewed for any complications and risks, defined as any adverse event delaying surgical progress or recovery along with any additional risk to patient safety. Criteria included interventions beyond those involved in undergoing routine general anesthesia. This included difficult intubation, reintubation, postoperative pulmonary edema, postoperative desaturations, and/or need for continuous positive airway pressure. The data obtained were stratified into results for intubation and special equipment needed along with airway visibility and intubation technique, reintubation, induction and supplemental drugs, neuromuscular blockade, neuromuscular blockade reversal, pain medications, body mass index, and overall anesthesia risk., Results: Thirty-two patients were reviewed with no severe adverse events such as reintubation, prolonged intubation, or postoperative pulmonary edema. Patients who were difficult to intubate or required nasal/oral airways failed to show any adverse outcomes., Conclusions: Patients undergoing surgery for OSA are considered to be at increased risk of complications. Review of 32 patients failed to show any life-threatening risks or complications., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To investigate voice change as a complication after uvulopalatopharyngoplasty (UPPP) with or without radiofrequency tongue base reduction (RTBR) in patients with obstructive sleep apnea., Study Design: Before and after study., Methods: Twenty-two patients with suspected velopharyngeal collapse only underwent uvulopalatopharyngoplasty (UPPP group). Twenty-five patients with velopharyngeal and retrolingual collapse underwent concurrent UPPP with RTBR (RTBR group). All patients were evaluated before surgery and at 8 weeks after surgery. Acoustic measures included mean fundamental frequency (mF0), maximal phonation time (MPT), jitter, shimmer, noise-to-harmonic ratio (NHR), hypernasality test, and the first three formant frequencies (F1, F2, F3) for sustained vowels. Voice handicap index (VHI) was used to determine subjective voice change., Results: Postoperative values for mF0, MPT, jitter, shimmer, NHR, hypernasality test, and F1 did not significantly change in either group following surgery. There were the significant decreases at the F2 of /u/ and the F3 of /o/ in the UPPP group, and at the F2 of /o/ and the F3 of /a/, /i/, and /o/ in the RTBR group. Postoperative VHI score was increased only in the RTBR group., Conclusions: UPPP and UPPP with RTBR have an impact on formant frequencies of vowels. Despite a relatively small number of patients, it is apparent that UPPP with RTBR influences VHI. Patients, especially professional voice users, should be advised of this before considering the surgery., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To determine whether snoring sound intensity measured after a first soft palate radiofrequency (RF) session for simple snoring helps predict the final result of the treatment., Study Design: Observational retrospective study., Methods: We conducted a retrospective review of 105 subjects presenting with simple snoring or mild sleep apnea. All patients underwent two to three sessions of RF-assisted stiffening of the soft palate. In addition, uvulectomy was performed in case of a long uvula, and two paramedian trenches were created in the presence of palatal webbing. Snoring sound intensity was evaluated by the bed partner after each session., Results: Eighty-six men and 19 women were included in the study. Mean age was 51.7 ± 9.8 years, and mean body mass index was 24.7 ± 4.4 kg/m(2) . The mean apnea/hypopnea index was 6.6 ± 4.2/h. The mean snoring sound intensity, as evaluated on a 10-cm visual analog scale (VAS), decreased from 8.2 ± 1.5 to 3.5 ± 2.2 after all sessions (P < .0001). A score of 3 was determined as being a score that satisfied the bed partner. Two groups were formed according to the final snoring sound intensity, using 3 as a threshold. Both groups had similar preoperative characteristics, but the snoring sound intensity was significantly lower after the first session in the group with final score <3 (P = .01). Similarly, a VAS score >7 after the first session was associated with a final score <3 in 30% of the cases., Conclusions: Snoring sound intensity after the first RF session helps predict the final outcome of RF-assisted stiffening of the soft palate for simple snoring., (Copyright © 2012 The American Laryngological, Rhinological and Otological Society, Inc.)

Unlabelled: OBJECTIVES/HYPOTHOSES: TORS (Trans Oral Robotic Surgery) has been demonstrated to be an acceptable alternative to chemoradiation for the treatment of early stage malignant lesions of the oropharynx, with equivalent tumor control and enhanced functional outcomes. Surgical ablation of tumors of the oropharynx under conditions of limited access, however, creates the need to adapt the robotic platform to surgical reconstruction and to assess reconstructive outcomes. We present our experience with the Facial Artery Musculomucosal (FAMM) flap with robotic assistance for the reconstruction of defects of the soft palate., Methods: We reviewed the records of five patients who underwent combined robot-assisted resection of malignant lesions of the oropharynx with immediate reconstruction. The reconstructions included four ispilateral and one bilateral FAMM flaps. Patients were assessed for complications and functional results., Results: Successful closure of the defect was achieved in all five patients. There were no major complications; however, three patients developed minor wound dehiscence and two were revised at the time of planned subsequent lymphadenectomy. All five patients achieved a good functional outcome., Conclusions: The FAMM flap is reliable and easy to raise and transfer, with the surgical robot making it a good candidate for reconstruction of moderate-sized defects created by TORS applied to malignancies of the soft palate. Minor wound dehiscence is not infrequent, but reconstructive outcomes are nevertheless good. A unilateral FAMM flap will reach to the contralateral border of the uvula and is best limited to defects with a width of 2 cm or less., (Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: The objective of this study was to evaluate the long-term effectiveness of palatal implants as the treatment of primary snoring., Study Design: Prospective longitudinal cohort study., Methods: This study compared snoring outcomes before and after soft palate implantation for patients diagnosed with primary snoring (no sleep apnea). Snoring severity was obtained by the subjects' sleep partners on a 10-point Likert scale. A paired Student t test compared the mean scale values preoperatively at week 52 and at the current 4-year follow-up. Body mass index for each patient was also compared to evaluate for any significant confounders., Results: Data were obtained from 23 patients out of 26 who were followed for the full study term. The follow-up time was on average 4 years following palatal implantation. A statistically (P < .016) and clinically significant improvement in the snoring scale was noted when comparing snoring severity between the preoperative and 4-year period and between the 52-week and 4-year scores. Although statistically significant improvement was found between the preoperative period and 52 weeks, there was a clinical deterioration in snoring scale scores between 52 weeks and 4 years. The mean (standard deviation) preoperative score was 9.5 (0.5), mean week-52 score was 5.0 (1.6), and mean 4-year score was 7.0 (1.8). Body mass index did not change through the observation interval., Conclusions: Soft palate implantation is a possible surgical technique with which to attempt to achieve subjective improvement of primary snoring severity. Subjective improvement, however, deteriorates significantly over time, and is only minimally sustained at 4 years postoperatively. This study provides new information on long-term palatal implant effectiveness., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: To study long-term results in patients undergoing uvulopalatal flap (UPF) for obstructive sleep apnea (OSA)., Design: Prospective, clinical trial at tertiary referral center., Material and Methods: A study was undertaken on 83 OSA patients with palatal obstruction based on radiography and physical findings. UPF was conducted to increase the airway space and data were analyzed., Results: Patients had a mean age of 36.5 ± 12.3 years and a mean body mass index (BMI) of 29.4 ± 4.3 kg/m(2) . The mean follow-up was 54.2 ± 8.9 months, with a range of 48 to 62 months. The mean baseline apnea-hypopnea index (AHI), short-term AHI, and long-term AHI were 45.6 ± 10.3, 13.4 ± 5.2, and 19.4 ± 5.1, respectively. The mean baseline lowest oxygen saturation (LSAT), short-term LSAT, and long-term LSAT were 82.6 ± 5.4%, 89.2 ± 4.8%, and 88.1 ± 3.2%, respectively. Forty-three patients (51.8%) had long-term success, and 15 patients(25.8%) had an increase in the AHI over the follow-up period such that they were no longer considered success by traditional AHI criteria. Serious complications were not encountered., Conclusions: UPF is a safe and effective procedure that results in long-term success for OSA. However, a regular follow-up is important because some patients will relapse in the long term., (Copyright © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with obstructive sleep apnea (OSA) by evaluating perioperative nasalance, nasality, voice, and articulation., Study Design: Prospective, comparative study., Methods: Twenty-four OSA patients selected for RP (two women and 22 men; mean age, 35 years) were enrolled for the study of velopharyngeal function in speech. The RP procedure involved removal of supratonsillar adipose tissue, preservation of all palatal muscular structure, splinting the lateral pharyngeal wall, and anterior advancing of the soft palate. Measurements of nasalance (vowel /a/, /i/, consonant /m/, oronasal, oral, and nasal texts), nasality (mirror-fogging test, degree of nasality, Gutzmann test and Bzoch hypernasality test), voice (acoustic analysis), and articulation (velar sound) were taken before RP and 3 months after the procedure and compared., Results: Comparative analysis of clinical measures showed that no significant differences were found following RP in nasalance (except for the vowel /a/), nasality, articulation, and voice. The only difference with regard to vowel /a/ showed, instead of an increase, a significant decrease of nasalance from 17.3 + or - 10.8 to 11.3 + or - 6.7 (P = .004), which may be attributed to the advancing and lifting of the soft palate in RP, leading to relaxation of the levator veli palatine and uvular muscles, which facilitates their contraction in velopharyngeal closure during particular vowel phonation., Conclusions: RP for OSA does not cause velopharyngeal insufficiency in terms of voice, nasality, and articulation in spite of anterior advancement of the soft palate, but does induce a nondetrimental change in nasalance.

Objectives/hypothesis: To investigate the efficacy of relocation pharyngoplasty as a surgical technique both to enlarge pharyngeal airspace and to decrease pharyngeal collapse in the treatment of obstructive sleep apnea (OSA)., Study Design: Prospective comparative study performed in a tertiary referred sleep center., Methods: Ten adult male OSA patients (median age of 38 years, median apnea-hypopnea index [AHI] of 41.6 events/hour, and median body mass index of 25.8 kg/m(2)) with favorable oropharyngeal structure were enrolled. Principal procedures of the relocation pharyngoplasty include tonsillectomy, removal of supratonsillar mucosa and adipose tissue, splinting the lateral pharyngeal wall by suturing the placating superior pharyngeal constrictor muscle to the anterior pillar, and advancing the soft palate by suturing the posterior pillar flap cephalad laterally to the supratonsillar fossa., Results: No patients experienced swallowing disturbance or change of voice after 3 months postoperatively. The median time for patients to return to normal nourishment was 15 days. Six months after the operation, there were statistically significant improvements in snoring (P = .005) and daytime sleepiness (P = .008). Repeated polysomnography revealed significant improvement in AHI (P = .005) and rapid eye movement period (P = .037). Furthermore, reduction in AHI following relocation pharyngoplasty was found in all patients., Conclusions: In selected patients, relocation pharyngoplasty by advancing the soft palate and splinting the lateral pharyngeal wall obtains significant improvement in subjective snoring and daytime sleepiness, as well as objective adverse sleep respiratory events and sleep architecture, while retaining normal pharyngeal function.

Objectives/hypothesis: Radiofrequency (RF) surgery of the soft palate (SP) is an established treatment option for the treatment of snoring. Due to its minimally invasive character, it has received attention in the management of mild obstructive sleep apnea syndrome (OSAS)., Study Design: The aim of this study was to assess the efficacy and the occurrence of adverse events after single-stage SP RF surgery in patients with mild OSAS in a randomized single-blinded placebo-controlled trial in an outpatient department at a tertiary care center, academic teaching hospital., Methods: Thirty-two patients with mild OSAS (apnea-hypopnea index [AHI] 5-15, body mass index <35) were randomized to receive a single session of RF surgery or placebo (insertion of applicator without energy delivery) with local anesthesia. The primary outcome measures were (AHI), Epworth Sleepiness Scale, and a 36-item short-form health survey quality-of-life questionnaire. The secondary measures were the soft tissue airway parameters in cephalometric radiographs, snoring scores, and rates of adverse events., Results: Neither objectively measured significances (active AHI 11.0 [5.0-9.0] to 13.0 [2.0-26.0] and placebo AHI 12.0 [5.0-8.0] to 11.0 [1.0-29.0], P = .628), nor were trends of a diminishing effect on symptoms of mild OSAS found in the treatment arms. No significant changes in the soft tissue airway parameters occurred. One patient (5.9%) in the active treatment group was cured., Conclusions: RF surgery of SP is not recommended as a single-stage approach in mild OSAS.

Objectives/hypothesis: The efficacy of combined radiofrequency (RF) surgery of the soft palate (RF-assisted uvulopalatoplasty [RF-UPP]) was demonstrated in a prospective study. Nevertheless, the data is based on short-term follow-up only, as it is the case with the majority of clinical studies regarding surgical treatment of snoring. Long-term follow-up is of particular importance in this context, as snoring relapses in a significant number of patients. The aim of this study was to assess the long-term efficacy of RF-UPP in the treatment of snoring., Study Design: Prospective clinical trial., Methods: Twenty-one patients with primary snoring (apnea/hypopnea index <15, body mass index [BMI] <32) were going through the initial trial. Patients had received two sessions of RF-UPP at the soft palate as previously described. For the present trial, all patients were contacted after approximately 18 months and asked to complete an additional follow-up questionnaire assessing current BMI, snoring (visual analogue scale), and the overall satisfaction with the procedure., Results: From the 21 initial patients, 19 (90%) answered the questionnaire. Mean follow-up was 19.8 +/- 4.9 months. The postoperative snoring scores showed an increase from 2.0 +/- 2.1 to 5.1 +/- 3.3 (P < .05) at long-term follow-up. Seven (37%) patients demonstrated long-term success (1.7 +/- 0.5), whereas seven patients experienced a relapse in snoring (8.1 +/- 1.4). BMI remained unchanged. Age, sex, BMI, or the length of follow-up did not influence long-term outcome., Conclusions: After RF-UPP of the soft palate, a relapse in snoring has to be expected at long-term follow-up in a subgroup of patients. At present, there are no prospective parameters which would predict long-term benefit.

Objective: To assess the effectiveness and adverse effects of radiofrequency ablation (RFA) of soft palate (SP) in snoring., Study Design: Systematic search of electronic databases. Only articles published in peer-reviewed journals were evaluated. Included were controlled or prospective studies with at least 10 adults (> or =18 years of age) without moderate/severe obstructive sleep apnea., Results: Of the 159 articles identified, 30 met the inclusion criteria: two randomized controlled trials (RCT), four clinical controlled trials, and 24 prospective uncontrolled studies. The only placebo controlled RCT indicated SP RFA to be superior compared to placebo. The other RCT, comparing different radiofrequency ablation generators, showed no evidence of differences in snoring treatment efficacy, and only minor differences in patient discomfort. In two of the controlled trials snoring relief obtained by SP RFA was comparable, and in three of them associated with less postoperative pain than other interventions. Radiologic results were contradictory with some trials reporting significant changes of the upper airways, whereas others did not. Neither long-term side effects nor major adverse events have been reported after., Conclusions: The review provides evidence that SP RFA is an intervention causing less postoperative pain than others, and the risk of adverse effects for the patient seems to be small. It may reduce symptoms of snoring, at least in the short term. However, most of the published SP RFA literature is based on observational studies with a short follow-up time, which precludes solid conclusions about the effectiveness of the procedure. Laryngoscope, 2009.

Objectives/hypothesis: Recent studies suggest that radiofrequency ablation (RFA) is a treatment option for patients with obstructive sleep apnea (OSA). This study investigates the effectiveness of RFA in treating OSA using a critical literature review and meta-analysis., Study Design: Critical literature review and meta-analysis., Methods: Two independent searches of PubMed 1966-present were performed to identify publications pertaining to RFA and OSA. Effectiveness of the procedure was measured by comparing the Epworth Sleepiness Scale (ESS), respiratory disturbance index (RDI), and lowest O2 saturation before and after tissue ablation., Results: Sixteen studies met the inclusion criteria. The study found a 31% reduction in short-term ESS (odds ratios (OR) 0.69, 95% confidence interval (CI) 0.63-0.75), which was maintained beyond 12 months (OR 0.68, 95% CI 0.43-0.73). Likewise, RFA resulted in a 31% reduction in short term (<12 month) (OR 0.69, 95% CI 0.61-0.77) and 45% reduction (OR 0.55, 95% C.I. 0.45-0.72) in long-term (>24 month) RDI levels. Short-term results of the lowest O2 saturations failed to demonstrate improvement (OR 1.03, 95% CI 0.88-1.20)., Conclusion: RFA seems to be a clinically effective tool that reduces ESS scores and RDI levels in patients with OSA syndrome. The procedure should be considered a valid treatment option for patients who refuse or are unable to tolerate continuous positive airway pressure.

Study Objectives: To evaluate the prognosis of mild obstructive sleep apnea in relation to different treatment modalities., Study Design: An open, retrospective, longitudinal follow-up study., Methods: Fifty adult patients diagnosed and treated for mild obstructive sleep apnea at the Department of Otorhinolaryngology at Kuopio University Hospital between 1998 and 2004 had a control polysomnography in 2005. The changes in apnea-hypopnea index (AHI) were observed in untreated (n = 28), operative (n = 11), and continuous positive airway pressure (n = 11) treatment groups at a long-term follow-up visit., Results: The mean follow-up period was 4 (range, 1.3-9.0; SD, 1.9) years. The untreated patients had a statistically significant increase in AHI (13.3, SD 18.3) at the follow-up. Half of these patients developed a moderate or severe degree of sleep apnea, and only 11% were cured. In patients who were treated with continuous positive airway pressure, the degree of obstructive sleep apnea became worse in 64% of cases, and in 27% of patients, the AHI returned to normal (<5). The degree of obstructive sleep apnea in operated patients deteriorated only in 18%, and in 27% of the patients, the AHI returned to normal (<5)., Conclusions: Mild obstructive sleep apnea has a natural tendency to worsen with time. Active treatment of mild obstructive sleep apnea appears, therefore, to be advisable.

Objectives: Despite the well-recognized consequences of obstructive sleep apnea (OSA), its treatment remains unsatisfactory. Therapeutic strategies are complicated by often poor adherence in the case of continuous positive airway pressure or the highly variable efficacy in the case of many upper airway surgeries. Computational models of the upper airway using finite element analysis to simulate the effects of various anatomic and physiologic manipulations on pharyngeal mechanics could be helpful in predicting surgical success., Study Design: Computational and physiologic study., Methods: Using representative OSA magnetic resonance images and experimentally measured upper airway dilator muscle activities, we developed a working two-dimensional and a partial three-dimensional model of the upper airway., Results: As predicted from experimental measurements, the OSA model airway has a closing pressure of -2 cm H2O. Manipulations such as palatal stiffening, palatal resection, and tongue stiffening all have demonstrable effects on pharyngeal mechanics. We have also developed a partial three-dimensional OSA model in which we simulate the mechanics of the pharyngeal airway in the mid-sagittal and parasagittal slices, spanning more than 1 inch in thickness. Using this model, we have observed important effects of tongue and palatal stiffening on anteroposterior collapse of the pharyngeal airway., Conclusions: Our data suggest that computational modeling is feasible and can be used to generate hypotheses for subsequent clinical trials regarding anatomic manipulations in OSA. We further believe that the goal of individualizing OSA therapy on the basis of underlying mechanisms could be facilitated by computational modeling.

Objectives: Sleep-related breathing disorders (SRBD) that cannot be treated conservatively are commonly treated using uvulopalatopharyngoplasty, although success rates are generally less than 70%. The purpose of this study was to assess a plasma-mediated radiofrequency (RF)-based coblation assisted upper airway procedure (CAUP) to treat SRBD patients determined to have obstruction localized to the upper (mid)-pharyngeal region., Study Design: Prospective case series (n = 40)., Methods: Six patients had socially bothersome snoring, and 34 patients had mild to moderate sleep apnea (apnea/hypopnea index [AHI] <20), with the primary level of obstruction (>50%) within the upper pharyngeal region as determined using whole night recordings, including airway pressure fluctuation monitoring (ApneaGraph, MRA-Medical Ltd, Gloucestershire, UK). CAUP consisted of making a lateral palatal incision, ablating three upward channels on each side of the midline (fan-shaped) into the soft palate using a plasma mediated RF-based device (ArthroCare Corporation, Austin, TX), and performing a partial uvulectomy. Clinical outcomes included the Epworth Sleepiness Scale (ESS), partner rating of snoring using a visual analogue scale (VAS), and night-time apnea and hypopnea events (AHI, hypopnea index [HI], apnea index [AI])., Results: Patients were 28 to 68 (46 +/- 12) years old; 28 (70%) were male. Preoperatively, clinical assessment scores (median +/- interquartile range) were as follows: ESS (11.0 +/- 3.0), VAS (8.15 +/- 1.00), AHI (9.58 +/- 5.58), HI (9.00 +/- 5.29), AI (0.333 +/- 0.625). After CAUP, no postoperative scarring, fibrosis, or any other clinically significant side effects were observed. Postoperatively (9.1 +/- 1.5; 7-15 mo), ESS (4.0 +/- 1.0), VAS (2.70 +/- 1.38), AHI (3.75 +/- 2.92), HI (3.58 +/- 2.50), and AI (0.167 +/- 0.167) were significantly improved (P < .001)., Conclusion: CAUP preceded by site-specific obstruction diagnosis using pressure recording is a well-tolerated outpatient treatment that is well suited for treating SRBD.

Objectives: To study the long-term quality of life outcomes of a group of unselected patients for the long-term effects of uvulopalatopharyngoplasty (UPPP)., Study Design: Retrospective chart review and telephone survey., Methods: Forty-nine patients who underwent UPPP between July 1980 and July 1983 and who had their medical records were reviewed and were asked to grade on a visual analogue scale (VAS) the clinical benefits and complications of UPPP after the surgery., Results: Forty-three (87.8%) males and six (12.2%) female patients were studied. Improvement in snoring, excessive daytime somnolence, and nocturnal arousals were seen after UPPP with decreased effectiveness after time. The most common complication of UPPP was velopharyngeal insufficiency (VPI) (28.5%); however, dry throat and swallowing difficulty tended to be more severe in those patients who had them. No correlation between the snoring and VPI VAS grades was observed. Forty-three patients had a preoperative sleep study and 22 patients a postoperative sleep study. There was lack of correlation between the significant subjective clinical improvement and their postoperative polysomnography., Conclusion: When undertaking UPPP, both subjective and objective benefits should be weighed against the risk of long-term ill effects. Patients should also be warned that the long-term side effects such as VPI, dry throat, and abnormal swallowing sensation might be more common than previously expected.

Objective/hypothesis: The objective of this study was to measure subjective and objective improvement after palatal stiffening in patients after uvulopalatopharyngoplasty (UPPP) who were experiencing persistence or recurrence of snoring with or without daytime sleepiness symptoms., Study Design: The authors conducted a prospective, nonrandomized study of 26 patients after UPPP who underwent the Pillar Implant Technique (PIT) as a revision procedure., Methods: Patients were selected to undergo revision PIT if they presented with recurrence or persistence of snoring after UPPP. Patients had mild or moderate obstructive sleep apnea-hypopnea syndrome (OSAHS) (apnea-hypopnea index [AHI] >5 and < or =40), persistent retropalatal obstruction, and a residual palate > or =2 cm. Some patients experienced daytime somnolence as well. Patients with severe OSAHS (AHI > or =40), Friedman anatomic stage IV, and/or nasopharyngeal stenosis were excluded. Pre-/postoperative snoring levels, Epworth Sleepiness Scale (ESS), SF-36v2 Quality of Life (QOL) questionnaires, and polysomnograms were obtained., Results: We completed data on 23 patients. Postoperative snoring levels (3.4 +/- 1.8) and ESS (8.7 +/- 1.8) significantly improved (P < .0001) compared with preoperative values (8.7 +/- 1.8 and 13.2 +/- 2.9). A total of 73.9% of patients improved subjectively. Seven of eight SF-36v2 QOL domains showed significant improvement (P < .05). Postoperative AHI and minimum oxygen saturation also improved significantly (P < .05). Objective cure was only achieved in 21.7% of patients., Conclusions: Revision PIT is effective in achieving subjective improvement of recurrent symptoms after UPPP. Objective cure was only obtained in 21.7% of patients. As a result of the safety and low morbidity of the procedure, it is an alternative to improve symptoms, especially snoring, in patients not willing to accept continuous positive airway pressure permanently or patients who refuse revision surgery.

Objectives: The aim of this study was to compare the effectiveness of the Er,Cr:YSGG (Waterlase) laser with KTP and CO2 lasers in laser assisted uvulopalatoplasty (LAUP) for treatment of snoring., Study Design: This is a prospective study of 63 patients who were treated for snoring by LAUP either with Er,Cr:YSGG (n = 21) or with KTP (n = 21) or CO2 lasers (n = 21). Histologic analysis was performed, and the effects of KTP and Waterlase on soft tissue were compared., Methods: Patients were examined by an ENT surgeon and tested with polysomnography. Probands who suffered from obstructive sleep apnea or had an apnea-hypopnea index of 15 or greater were excluded from the study. The remaining patients were assigned to either Er,Cr:YSGG, KTP, or CO2 laser therapy. The three lasers were compared from a postoperative recovery point of view by immunohistochemical examination., Results: Pain medications were used on average for 4.1, 6.5, and 10.1 days, and the times to return to normal diet were on average 4.5, 6.8, and 8.6 days in the Er,Cr:YSGG, KTP, and CO2 groups, respectively. Two cases of bleeding were observed in the CO2 group. Foreign body sensation occurred in 14%, 19%, and 19% of subjects in the Er,Cr:YSGG, KTP, and CO2 groups, respectively. Velopharyngeal insufficiency was noticed in one KTP treated patient; however, it was transient. Snoring and apnea-hypopnea index was significantly reduced in all groups. Significantly larger coagulation of soft tissue was found in the KTP group than in the Waterlase group., Conclusions: Patients treated with Waterlase recovered more quickly in comparison with patients in the KTP and CO2 groups, which was confirmed by immunohistochemical findings. The laser techniques did not differ in effectiveness.

Objectives: To compare the long-term (3-year) outcome and effects of continuous positive airway pressure (CPAP) and extended uvulopalatoplasty (EUPF) treatment on patients with obstructive sleep apnea syndrome., Methods: Eighty-four patients who received CPAP titration and bought a CPAP machine to use from March 2000 to October 2001 were included as the CPAP group. Another 55 patients who underwent EUPF surgery were included as the EUPF group. Overnight polysomnography was performed 6 months and 3 years after CPAP titration or EUPF. The disease-specific questionnaire-Snore Outcome Survey (SOS), Epworth Sleepiness Scale (ESS), and the generic health questionnaire-MOSF-36 were administered at the 6-month and 3-year follow-up examinations., Results: The age, body mass index, respiratory disturbance index, and ESS before treatment were higher in the CPAP group. The snore index was higher in the surgery group. Fifty-four patients (64.3%) in CPAP group continued treatment for 6 months; the success rate for EUPF at 6 months was 82%. The polysomnographic variables improved significantly in both groups. Improvements in the SOS and ESS scores were better in surgery group than the CPAP group. The subscales of SF-36 in surgery group were more than those in CPAP group., Conclusions: EUPF had a better effect on snoring than CPAP 6 months after treatment in patients with obstructive sleep apnea syndrome (OSAS). This effect had gradually declined at the 3-year follow-up examination. Improvement in the quality of life of OSAS patients receiving EUPF is equal to those receiving CPAP treatment.

Objectives: This study aimed to evaluate the effectiveness of uvulopharyngopalatoplasty (UPPP) plus genioglossal advancement (GA) for severe obstructive sleep apnea (OSA) patients and to determine the predictive factors for surgical success., Study Design: Prospective case series., Methods: Patients with apnea-hypopnea index greater than 40/hour during an overnight sleep study and who were reluctant to receive nasal continuous positive airway pressure (nCPAP) therapy were included. Basic data were obtained along with physical examination, cephalometric measurements, and Epworth Sleepiness Score (ESS) questionnaire. All patients received UPPP plus GA under general anesthesia. Overnight sleep study was repeated at least 3 months after operation along with cephalometry and ESS questionnaire., Results: Forty-four patients with severe OSA were enrolled in this study. The overall success rate was 52.3%. Preoperative apnea index (AI) was the only significant predictor for the success of operation (P = .007). Furthermore, patients with AI less than 25/hour had a higher success rate than those with AI 25/hour or greater (odds ratio 13.1)., Conclusion: Patients with AI less than 25/hour unwilling to receive nCPAP therapy could be more suitable for UPPP plus GA in terms of the success rate.

Objective: To undertake a retrospective, questionnaire review of surgery for heavy snoring, to ascertain patients' perception of the procedure and its effect on their snoring., Patients and Methods: A specifically designed postal questionnaire was sent to 261 patients who underwent snoring surgery at University Hospital Aintree, Liverpool, UK, between April 1993 and March 2000. One hundred ninety-three patients responded (73.9%), including 151 men and 42 women. Mean age was 49.0 years (range, 24-74 yrs)., Results: Twenty-two patients had a uvulopalatopharyngoplasty, 53 a traditional laser palatoplasty and uvulectomy, and 118 an uvulopalatal elevation palatoplasty. There was a 26% patient-reported postoperative infection rate. Morbidity regarding postoperative swallowing, pharyngeal sensation or voice change appeared minimal. Seventy-six percent scored postoperative pain as "moderate" or "severe," irrespective of the operation performed (P = 0.989). Thirty-seven percent of patients perceived an improvement in postoperative sleep quality. Twenty-four percent of patients reported no improvement in snoring after surgery. Forty-three percent reported an initial improvement that was not sustained for 2 years, whereas 34% of patients benefited from an improvement sustained for longer than 2 years, irrespective of the operation performed (P = 0.143). Only 47%, with hindsight, would have undergone surgery., Conclusion: These data highlight that snoring surgery has a high postoperative morbidity rate and a high failure rate. Research endeavors should be directed to the development of a strategy which enables reliable preoperative identification of patients' who enjoy sustained benefit postoperatively.

Objectives: To investigate the incidence of complications after temperature-controlled radiofrequency (TCRF) treatment of the inferior turbinates, palate, and tongue. To compare these complication rates with those reported in the literature., Study Design: Prospective, observational study., Methods: All patients treated with TCRF to the inferior turbinates, palate, and tongues during a 12-month period were included. Data were collected for parameters of energy delivery and the development of complications., Results: One hundred thirty-six patients were treated with a total of 470 TCRF lesions. The overall incidence of minor complications was 1.2% (6/470 lesions); there were no complications of moderate or major severity., Conclusion: The incidence of minor complications after TCRF in this series was low, and there were no complications of greater severity. These findings are in stark contrast with some previously published papers with higher complication rates. These significantly higher rates may be caused by a marked learning curve, problems in patient selection and the technique of application, excessive energy delivery, and perioperative management.

Objectives: To determine whether patients with obstructive sleep apnea who undergo uvulopalatopharyngoplasty (UPPP) have a significant incidence of postoperative complications that would justify overnight postoperative observation in the hospital., Study Design: Part 1: review of published medical literature to determine incidence of postoperative complications. Part 2: retrospective review of 117 patients undergoing UPPP with or without additional procedures., Methods: A literature search for existing studies describing the postoperative complications after UPPP for obstructive sleep apnea was conducted. After this, the records of 117 patients who had undergone UPPP at a university-based medical center during a 5-year span were reviewed., Results: Respiratory events occur in 2% to 11% of cases. These include airway obstruction (e.g., laryngospasm), postobstructive pulmonary edema (POPE), and desaturation. Airway obstruction occurred in the immediate postoperative setting. POPE was rare and usually occurred within minutes after the conclusion of the surgical procedure. Desaturation could occur at any time, but the severity was usually equivalent to that found on preoperative sleep study. Hemorrhage occurred in 2% to 14% of cases and had a biphasic incidence, occurring either immediately postoperatively or several days after surgery. Depending on definition, hypertension was observed in between 2% and 70% of patients postoperatively. This was most commonly diagnosed and treated in the immediate postoperative setting. In most reports, arrhythmia and angina occurred in less than 1% of cases., Conclusions: The majority of complications after UPPP with or without additional procedures occur within 1 to 2 hours after surgery. Postoperative oxygen desaturation is usually no worse than that that was observed on preoperative polysomnography findings. A 2 to 3 hour observation period may be suitable for patients after UPPP; if a patient experiences no complications and is maintaining adequate oxygenation and analgesia, same-day discharge from recovery room may be considered.

Objectives: The primary objective is to determine the effectiveness of multilevel (tongue base and palate) temperature controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS). The secondary objective is to compare multilevel TCRFTA to nasal continuous positive airway pressure (CPAP)., Study Design and Methods: The study is a controlled case series of one investigator's experience with multilevel TCRFTA for patients with OSAS. Twenty-two subjects with mild to severe OSAS, without tonsil hypertrophy, completed multilevel TCRFTA (mean 4.8 tongue base and 1.8 palate treatment sessions) and had both pre- and posttreatment polysomnography. Primary outcomes included change from baseline in apnea/hypopnea index (AHI), daytime somnolence, and reaction time testing measured 2 to 3 months after TCRFTA. Secondary outcomes included change in other respiratory parameters, OSAS related quality of life, and upper airway size. Comparison of 18 patients treated with TCRFTA for mild to moderate OSAS (AHI > 5 and < or = 40) is made with 11 matched patients treated with nasal CPAP for mild to moderate OSAS., Results: Multilevel TCRFTA significantly improved AHI (P = .001), apnea index (P = .02), as well as respiratory and total arousal indices (P = .0002 and P = .01). Significant improvement with moderate or large treatment effect sizes were noted for OSAS related quality of life (P = .01) and daytime somnolence (P = .0001), with a trend toward significant improvement in reaction time testing (P = .06), with mean posttreatment normalization of all three outcome measures. Fifty-nine percent of subjects demonstrated at least a 50% reduction in AHI to less than 20. The targeted upper airway, measured in the supine position, demonstrated a trend toward significant improvement in mean cross sectional area (P = .05) and volume (P = .10). Side effects of TCRFTA were infrequent, mild, and self-limited. No significant correlation between pretreatment parameters and outcome improvement was noted. Nasal CPAP resulted in significant improvement in AHI (P = .0004) to near normal levels, with an associated improvement in OSAS related quality of life (P = .02) and a trend toward significant improvement in daytime somnolence (P = .06). Reaction time testing demonstrated no significant improvement (P = .75). No significant differences were seen for change in AHI, OSAS related quality of life, daytime somnolence, or reaction time testing between multilevel TCRFTA and CPAP., Conclusion: Multilevel (tongue base and palate) TCRFTA is a low-morbidity, office-based procedure performed with local anesthesia and is an effective treatment option for patients with OSAS. On average, abnormalities in daytime somnolence, quality of life, and reaction time testing demonstrated improvement from baseline and were normalized after treatment. Polysomnographic respiratory parameters also demonstrated significant improvement with multilevel TCRFTA.

Objective: The role of the lateral pharyngeal muscular walls in the pathogenesis of obstructive sleep apnea hypopnea syndrome (OSAHS) is crucial. My objective is to describe a surgical procedure for splinting the lateral pharyngeal walls in patients with OSAHS and report the initial results., Study Design: Prospective randomized pilot study performed in an academic tertiary center as part of a doctoral thesis., Patients and Methods: Ten adults with OSAHS, originally selected for treatment with uvulopalatopharyngoplasty, underwent the lateral pharyngoplasty procedure, which consists of a microdissection of the superior pharyngeal constrictor muscle within the tonsillar fossa, sectioning of this muscle, and suturing of the created laterally based flap of that muscle to the same-side palatoglossus muscle. In addition, a palatopharyngeal Z-plasty is performed to prevent retropalatal collapse., Results: Lateral pharyngoplasty improved sleep and daytime symptoms related to OSAHS. After at least 6 months of follow-up, the median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) and the median total sleep time spent in rapid eye movement (REM) sleep and in stages 3 plus 4 non-REM sleep increased from 14.1% to 22.1% (P =.059) and from 5.3% to 16.3% (P =.037), respectively. Also, there was statistically significant improvement in snoring, daytime sleepiness, and overall impact of the disease on quality of life. Swallowing disturbances lasted a median of 14.5 days after the surgeries, and all patients returned to normal subjective swallowing function in the follow-up., Conclusions: Lateral pharyngoplasty is a safe and straightforward approach to lateral pharyngeal muscles and has produced appreciable benefits for OSAHS patients.