*Michał Michalik, Adrianna Podbielska-Kubera, Agnieszka Dmowska-Koroblewska
Diode laser-assisted uvulopalatoplasty using palisade technique
Leczenie chrapania metodą korekcji podniebienia miękkiego z wykorzystaniem lasera diodowego w technice palisadowej
Department of Otolaryngology, MML Medical Center, Warsaw, Poland
Head of Department: Michał Michalik, MD, PhD
Wstęp. Drożność dolnej części górnych dróg oddechowych zależy od stabilnego napięcia mięśni gardła, podniebienia miękkiego i języka. Konsekwencją zmniejszenia napięcia mięśni oddechowych jest powtarzające się całkowite lub częściowe zwężenie dróg oddechowych. Wówczas przepływające powietrze wywołuje drgania tkanek miękkich, które słyszane jest jako chrapanie.
Materiał i metody. W badaniu brało udział 34 pacjentów: 27 mężczyzn i 7 kobiet. Zastosowano leczenie chrapania metodą korekcji podniebienia miękkiego z wykorzystaniem lasera diodowego dwutlenkowęglowego, o długości fali 810 nm, mocy 5 W oraz długości impulsacji 4 sekundy.
Przed wykonaniem badania pacjenci zostali poddani ocenie laryngologicznej, zebrano wywiad dotyczący chorób przewlekłych. Ponadto pacjenci wypełnili 2 ankiety: kwestionariusz do diagnostyki przesiewowej zaburzeń oddychania w czasie snu oraz kwestionariusz Skali Senności Epworth. Dodatkowo wykonano badanie tomografii komputerowej 3D oraz rynometrię akustyczną. Wszystkie badania powtórzono 3 miesiące po zabiegu.
Wyniki. Zabieg wykonano u 34 osób. Ustąpienie dolegliwości zaobserwowano u 21 osób, a zmniejszenie objawów – u 13 osób. W grupie badawczej nie znaleźli się pacjenci, u których nie nastąpiłaby poprawa. Żaden z pacjentów nie zgłosił powikłań.
Wnioski. U pacjentów uzyskano dobry efekt usztywnienia struktur podniebienia, co przyczyniło się do ustąpienia chrapania. Do zalet stosowania lasera diodowego w technice palisadowej zaliczamy bezpieczeństwo stosowania, małą inwazyjność, krótki czas gojenia, minimalne ryzyko powikłań. Zabieg przeprowadzany jest w trybie ambulatoryjnym, w znieczuleniu miejscowym.
Introduction. The patency of the lower part of the upper respiratory tract depends on the muscle tone of pharynx, soft palate and tongue muscles. The consequence of the lowered tone of these muscles is recurrent total or partial narrowing of the airways. In this case, the turbulent airflow causes soft tissue vibration, which is heard as snoring.
Material and Methods. The study included 34 patients: 27 men and 7 women. Carbon dioxide diode laser-assisted uvulopalatoplasty was employed. The diode laser with a wavelength of 810 mm, power of 5 W, and pulse length of 4 seconds was used.
Before the procedure, all the patients underwent laryngological assessment. Medical history of the patients was also collected. In addition, the patients completed 2 questionnaires: a sleep disorder screening questionnaire and Ephworth Sleepiness Scale. Moreover, a 3D CT scan and acoustic rhinometry were performed. All the tests were repeated 3 months after the procedure.
Results. The procedure was performed in 34 patients. Complete clinical response was observed in 21 cases, and a partial response was seen in 13 cases. There were no patients in the study group who had not experienced at least a partial improvement of symptoms. None of the patients reported any complications.
Conclusions. Good clinical outcome was obtained in all the patients after obtaining palatal stiffening, which contributed to the resolution of symptoms. The advantages of diode laser-assisted uvulopalatoplasty using palisade technique include the safety of the procedure, minimal invasiveness, short healing time, and a low risk of complications. The procedure is performed on an out-patient basis under local anesthesia.
Sleep breathing disorders
Sleep breathing disorders include upper airway resistance syndrome, obstructive sleep apnea, and primary snoring (1).
The patency of the lower part of the upper respiratory tract (i.e. not including nasal cavity) depends on the muscle tone of pharynx, soft palate and tongue muscles (1). The major part of the upper and lower airways are supported with osseous (nose, larynx) or cartillagenous structures, thus maintaining their patency (1). Pharyngeal walls, on the other hand, consist entirely of soft tissues. The pharyngeal patency is maintained by the muscle tone of muscles consisting the anterior and lateral pharyngeal walls (1).
The consequence of the lowered tone of these muscles is recurrent total or partial narrowing of the airways (1). In this case, upper airway negative pressure during inspiration is higher than the tone of the stabilizing muscles. As a consequence, oropharyngeal isthmus narrows, and the turbulent airflow causes soft tissue vibration, which is heard as snoring (fig. 1) (1). The air velocity increases at the narrowest part of the airways (Bernouilli effect) (2). When critical closing pressure is reached, airway narrowing or closure ensues (2). Narrowing or closure of upper airways may occur along their entire length, but most frequently, oropharynx and laryngopharynx are affected (1). The following hypoxia and hypercapnia cause increased respiratory effort and awakening, which contributes to an increase of the muscle tone and restoring pharyngeal patency. The resulting short-term hyperventilation allows to fall back to sleep (2).
Fig. 1. Comparison of normal airway vs. airways in obstructive sleep apnea
Snoring is the vibration of upper respiratory structures and the resulting sound due to obstructed air movement during breathing (3). In the initial stage, snoring can go unnoticed by the patient, however, it is burdensome for the patient’s family. The results of a poll performed by TNS Polska in 2016 commissioned by MML Medical Center show that the number of patients diagnosed with snoring has been growing in the recent years, which is a result of a more universal access to diagnostics, as well as of the increased awareness of the patients (4). Snoring directly affects the quality of sleep and, in the opinion of the respondents, may result in a number of health problems (4). Snoring is observed in ca. 20% of men and 5% of women aged 30–35 (3). The prevalence increases with age. In the population of over 60 years of age, the prevalence of persons snoring is estimated at 60% in men and 40% in women (3).
The most serious complication of snoring is obstructive sleep apnea (5). Obstructive sleep apnea (OSA) is characterized by repetitive episodes of shallow or paused breathing during sleep, associated with a reduction in blood oxygen saturation and awakening (5). Sleep apnea is observed in the majority of patients who snore (3). Main complications of sleep breathing disorders include constant tiredness, xerostomia, headaches, daytime sleepiness, cognitive impairment, as well as depression (4). OSA is also associated with an increased risk of serious comorbidities, such as cardiovascular diseases, cerebrovascular accidents, diabetes mellitus, hypertension, and post-operative cardiovascular and respiratory complications (5). Cardiovascular Health Study (6) confirmed the relationship between OSA symptoms, including daytime sleepiness, apnea and snoring with higher fasting glucose and 2-hour postprandial glucose, as well as decreased insulin sensitivity.
Snoring may be a result of pathologies in the nasal cavity, pharynx, larynx, or all of these structures (5). The pathologies of the nasal cavity include nasal turbinate hypertrophy, deviated septum, and nasal polyps (5). The main pharyngeal anomalies that may be responsible for snoring comprise: uvular hypertrophy, macroglossia, flaccid or hypertrophied soft palate, tonsillar hypertrophy, and drooping lateral pharyngeal walls (5).
Figure 2 presents a computed tomography scan of a patient with restored normal airway patency after the surgery. Figure 3 presents a 3 dimensional computed tomography reconstruction that allows to determine the level of the obstruction.
Fig. 2. Computed tomography scan presenting a restored airway patency after surgery
Fig. 3. Determining obstruction level (marked with an arrow) in 3D CT reconstruction
Diagnostics and treatment of snoring
Snoring is an indication for a laryngological consultation and diagnostics. The first stage of diagnostics comprises of a detailed interview and physical examination. Next stages include qualification for nose, palate, and tongue surgery (5).
Several questionnaires have been developed to identify patients with an increased risk of snoring.
Questionnaires consist of questions concerning the signs of sleep breathing disorders (e.g. daytime fatigue or sleepiness), comorbidities (e.g. hypertension, obesity), as well as individual risk factors of the patient (age, sex, neck size) (7).
Among the most frequently used questionnaires is the STOP-BANG questionnaire. The questionnaire focuses on the following signs and risk factors: snoring (S), tiredness (T), observed stop of breathing (O), blood pressure (P), BMI over 35 (B), age over 50 (A), large neck size (N), and gender – male (G) (1). Another option is to use the Berlin Questionnaire (BQ), which assesses the presence and frequency of snoring, presence of apnea, daytime sleepiness, hypertension, and obesity (1). BQ a has high sensitivity (69–86%) and specificity (56–95%) in OSA diagnosis (5).
Epworth Sleepiness Scale is a useful tool as well. It is used to assess daytime sleepiness. The patient is asked to assess his chance of falling asleep in 8 different settings (8). Scored of 0–24 points are obtained. A result of above 10 points suggests sleep breathing disorder, as opposed to generalized fatigue (4).
The questionnaires alone are considered to be insufficient for screening (5). In addition to questionnaires, polysomnography, drug-induced sleep endoscopy, 3D computed tomography, laboratory tests, and home sleep apnea testing are used in the diagnostic process.
Polysomnography is a standard for the diagnosis of sleep breathing disorders (2, 7). This method employs multiple sensors that allow to simultaneously record the air flow, blood oxygen saturation, respiratory effort, and electrical activity of heart, brain, eyes, and muscle. Additional sensors include sensors of body position, chest, abdomen, and limb movements, as well as cameras and microphones (9). Polysomnography is expensive, time-consuming, and requires specialized equipment in a sleep laboratory and qualified personnel (9).
Polygraphy is a simplified version of polysomnography. It can be used as a screening test and performed in a hospital or at home (10). Polygraphy does not include electroencephalography, electrooculography, and muscle tone measurement. It is less precise than polysomnography, however, it is usually enough to make the right diagnosis (10). In some cases, it may be necessary to perform full polysomnography (10).
Three-dimensional computed tomography (CT) reveals sites of obstruction in the upper respiratory tract, including many abnormalities associated with snoring, including deviated nasal septum, nasal turbinate hypertrophy, pharyngeal and tonsillar hypertrophy, as well as macroglossia or hypertrophied soft palate (11). The advantages of 3D CT include being painless, non-invasive, and quick.
It is possible to perform a home sleep apnea testing. This testing is indicated in adults aged from 18 to 65 with a high probability of moderate to severe OSA, as well as in persons in which it is not possible to perform polysomnography for safety reasons or due to the need to remain immobile, moderate to severe respiratory disease, neuromuscular disease, and cardiac insufficiency (8). Home sleep apnea testing are a useful supplement to the diagnostics of obstructive sleep apnea, as it offers a simple, objective and cost-effective tool to assess the symptoms of OSA. Home sleep apnea testing may, however, underestimate the severity of sleep breathing disorders. Moreover, it is not known to what extent the test time registered by the device represents the actual sleep (12).
Choosing the right treatment method depends on many factors that affect the anatomy of the head and neck region. These factors include, among others, age, sex, body weight, and race (5). In addition, symptoms reported by the patient should be taken into account (5). It is crucial to determine the obstruction site that is the cause of apnea and snoring. In parallel with the surgical treatment, lifestyle changes are necessary. These include: weight loss, smoking cessation, avoiding intake of sedatives, caffeine restriction, avoiding alcohol consumption in the evening, reducing noise levels in bedroom and its adequate ventilation, comfortable bed, appropriate amount of sleep, and maintaining correct body position during sleep (2, 5).
In the treatment of snoring and apnea, it may be useful to introduce devices and techniques that facilitate breathing (CPAP – continous positive airway pressure) (13). Oral appliances (OAs) are frequently used, as they improve the patency of upper respiratory tract by changing the position of the tongue and related structures of the upper respiratory tract (13).
Sublingual nerve stimulation is effective in patients with multilevel obstruction in the upper respiratory tract (14).
Nasal and sinus surgery improve upper respiratory tract patency and increase the efficacy of CPAP and oral appliances (2). In case of pathologies of the nasal septum, septoplasty is performed (2). Another cause of difficulty in nasal breathing is turbinate hypertrophy. In these cases, conchoplasty is performed. Tonsillectomy is currently a standard surgical treatment for sleep breathing disorders in children caused by tonsillar hypertrophy (6, 15). Surgical procedures in patients with sleep apnea also include baratric surgery facilitating weight loss, as well as tracheostomy (16). Tracheostomy is indicated in patients who refused CPAP treatment and in patients in whom other surgical approaches failed (17).
Advanced surgical treatment methods for apnea and snoring include multilevel surgery – uvulopalatopharyngoplasty, tongue surgery, mandibular surgery, etc.
Uvulopalatopharyngoplasty consists of surgical removal of uvula and part of soft palate in order to widen oropharyngeal isthmus and eliminate obstruction present in the oropharynx (1). Maxillomandibular advancement surgery (MMA) moves mandible forward.
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