Sleep Apnoea did not have many surgical options before the 1980s. The only treatment for severe airway collapse during sleep was a tracheostomy, which was not a good option for many patients. Many had psychological issues related to such surgery.
UPPP and Fujita and Colleagues
The earliest performed surgery was on the soft palate. These were first done in Japan by Fujita and Colleagues in the early 80s. They described the earliest versions of UPPP or "soft tissue surgery on the soft palate". Half the patients benefitted by reduction of apnoea events, but the other half had minimal benefit. Inability to predict who may get better continued to be a puzzle for surgeons during this early phase.
Friedman staging and UPPP
In the late ’90s, for the first time, Feedman documented a predictive tool for UPPP. He documented those with the largest tonsils and smallest tongues (Friedman I) had 80% success with UPPP. Those with small tonsils and Big tongues (Friedman III) had very poor outcomes. Concern was that majority of adult patients didn’t belong to the freedman I group; hence surgery only suited a limited section of the population.
Uvulopalatal Flap
Uvulopalatal flap is when the mucous membrane is removed from the front part of the Uvula and part of the soft palate. The Uvula is then folded, pulled forward and sutured on the soft palate. This operation showed some promise, with 80% improvement in a carefully selected group of patients with collapse ONLY at the palate level.
Laser and Soft-palate
LAUP or laster assisted uvulopalatoplasty (burning the sides of the Uvula with a laser) has shown mixed results. Its main benefit was that it could be done as a day procedure and at times in the outpatient setting. However, the pain was no different from bigger operations.
Positive outcomes were limited to a select group with soft palate collapse only. That meant only a small number of patients would benefit from such procedures. Some studies have shown worsening of apnoea in some due to bad scarring of the palate.
Other Outpatient Procedures for Snoring
These procedures are generally seen as “high tech” procedures offered to patients who wish for less invasive outpatient options. As such, the cost is high, and often these procedures need to be repeated to maintain benefit. Their aim is to reduce snoring, but not aimed at curing sleep apnoea.
Such procedures include injection snoreplasty, radiofrequency procedures on the palate and palatal implants. All these aim to stiffen the vibrating soft palate, thereby by reduce snoring. Palatal implants generally have a low risk and have shown to reduce snoring at one year. However, there are strict selection criteria to have success. Those with sleep apnoea are unlikely to benefit, though these will remain attractive for snorers happy with an expensive outpatient procedure.
Addressing the Side Walls
Then there were further modifications to the UPPP initially described by Fujita. This was by some form of resection of the pharyngeal muscles and repositioning of those muscles to expand the airway. These operations proved to be superior techniques to plain UPPP, as they also addressed sidewall collapse. Some studies showed unto 80% success in patients who were not overweight. Modern soft palate surgeries described below have evolved from these, and incorporate some form airway expansion.
MODERN SOFT TISSUE SURGERY: Modified UPPP and BRP
In 2013 Stuart MacKay from Australia demonstrated success even in some groups with poor surgical anatomy. This was by combining a "Modified UPPP" procedure (which addressed the sidewall collapse) with Coblation of the tongue to reduce tongue base collapse.
In 2017 Vicini from Italy published “Barbed Reposition Pharyngoplasty (BRP)" .....“We are on the giant’s shoulders” . In his technique, he used a barbed suture technique to give the soft palate a significant lift and WIDEN the airway. He anchored the back of the tonsil muscles to a very thick fibrous part called pterigomandibular raphe, pulling the airway wide open.
These two methods have shown the most consistent results to date. Furthermore, they both have shown limited risks.
CSSC TECHNIQUE: MODIFIED BRP AND TONGUE CHANELLING
We have, over the last three years, adapted a hybrid of both the above operations. We have further modified those techniques with careful observation and reserach. Essential aspects are as follows
-Use of symmetric barbed suture -size 0 (largest available )
-Lowering the soft palate incisions and making them at least 1.5 cm away from the Uvula to prevent scaring of the soft palate.
-Using a "suture noose" around the back muscle (posterior pillar) to reduce wound breakdown.
-At the time of surgery, use of soft plastic buffers within the suture lines to prevent “cheese-wiring” of muscles.
-Use of the pterigomandibular raphe (v fibrous solid tissue) to anchor muscles as above.
-Suture direction modified to distribute the forces better, thereby reduce wound breakdown.
Further, at CSSC we are developing a better predictive tool to inform our patients of their likely outcomes.
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