轻及中度阻塞性睡眠呼吸暂停低通气综合征术式选择

目的探讨轻、中度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)患者不同腭咽成形术(uvulopala to pharygoplasty,UPPP)术式选择与预后的关系。方法经多导睡眠监测(polysomnography,PSG)及Muller动作纤维喉镜行上气道检查,确诊轻、中度OSAHS患者66例,阻塞平面在口咽部(Ⅱ型),行不同术式UPPP治疗一年后进行随访,比较术前及术后一年的数据,对其资料行统计学处理后进行分析。结果66例患者中,采用软腭部分切除的36例与不行软腭部分切除的30例,其睡眠呼吸暂停低通气指数(apnea hypopneaindex,AHI)有明显不同,前者明显低于后者,P<0.001;术后每小时呼吸暂停次数前者远比后者少,P<0.05。结论轻、中度OSAHS患者行UPPP治疗时,应选择行软腭部分切除术式,其术后各项指标可达正常。     

Surgery of the palate and oropharynx

Progress in successful surgical treatment of the obstructive sleep apnea/hypopnea syndrome (OSAHS) has been based on adjunctive treatment of the hypopharynx. Still the palate and oropharynx are the major areas of intervention, and certainly the most commonly operated upon. To ensure a successful outcome, appropriate surgical candidates must be identified. The authors present a method of clinical staging based on the position of the tongue relative to the soft palate as well as the size of the tonsils, aimed at identifying the most likely level of obstruction in patients who have OSAHS. We also present several surgical techniques that address obstruction at the level of the soft palate and oropharynx.     

Modified hyoid suspension for therapy of sleep related breathing disorders. operative technique and complications

BACKGROUND:: Concerning the therapy of obstructive sleep apnea (OSA) the discrimination between either retropalatal or retrolingual site of obstruction seems to be an oversimplification. Thus modern surgical concepts address both anatomical areas. Minimal invasive surgical techniques treating the soft palate have recently been developed while there is still an ongoing development concerning the base of tongue. Methods: A less invasive modification of the hyoid suspension to the thyroid cartilage, originally described by Riley, is presented as treatment modality for sleep related breathing disorders. Between October 2000 and March 2001, 14 patients underwent modified hyoid suspension within a multi-level surgery concept. The operative technique manages with only one wire-suture and does not include myotomies and intersection of the ligamenta stylohyoidea. Results: All together 10 male and 4 female subjects with a mean age of 50.9 years were included in the analysis. Preoperatively the mean apnea hypopnea index (AHI) was 18.4. The procedure was well tolerated. Neither increased postoperative pain nor increased requirement of analgetics was observed. Substantial side-effects were one case of seroma and 9 cases of transitory dysphagia. The retrolingual airway space increased significantly after surgery. Conclusions: These preliminary results are promising. The presented modified hyoid suspension is time-effective and shows less postoperative morbidity. Therefore it might become a suitable treatment modality within the multi-level surgery concept for sleep related breathing disorders.     

Cephalometric analysis and surgical treatment of patients with obstructive sleep apnea syndrome. A preliminary report

Oropharyngeal soft tissue profiles were studied by cephalometric analysis in 25 patients with obstructive sleep apnea syndrome (OSAS) and 10 controls. The length of the soft palate was significantly longer in patients (mean 48 mm) than in controls (mean 35 mm), as was the distance of close contact between the tongue and the soft palate. The thickness of the soft palate measured in the midsagittal plane was larger (mean 14 mm) than in the control group (mean 11 mm). The hyoid bone was more inferiorly positioned in patients than in controls, apparently giving the tongue a more upright position with more of the tongue tissue at the hypopharyngeal level than found in normals. In patients, the nasopharyngeal airway space, as well as the oropharyngeal airway space, had significantly reduced anteroposterior dimensions. Based on these data a new and modified surgical technique for treatment of OSAS patients has been developed. The surgical procedure is described, and some preliminary results concerning the effect of this operation in 16 patients are reported.     

阻塞性睡眠呼吸暂停患者软腭平面的手术方式及其应用

阻塞性睡眠呼吸暂停综合征(OSAS)患者中常见软腭平面狭窄,解除该平面狭窄最经典的手术方式是悬雍垂腭咽成形术(UPPP)。本文以UPPP为基础,对OSAS患者软腭平面的各种手术方式及疗效进行综述。     

Histologic and physiologic effects of electrocautery, CO2 laser, and radiofrequency injury in the porcine soft palate.

OBJECTIVES: This study was undertaken to compare the effects of electrosurgery, CO2 laser, and radiofrequency on the histological structure and physiological properties of the soft palate. These surgical techniques are used for stiffening and reducing the soft palate in the treatment of snoring and mild sleep apnea. STUDY DESIGN: Fifteen pigs were divided into five groups. METHODS: group 1 underwent electrosurgery incision of the lateral soft palate and excision of the uvula. Group 2 underwent the same procedure with the CO2 laser. Group 3 underwent CO2 laser ablation of the midline soft palate mucosa. Group 4 underwent radiofrequency volumetric reduction. Group 5 served as control. After 5 weeks the animals were sacrificed. Soft palate mucosa and muscle were subjected to tensiometric and histological analysis. Statistical analysis of tensiometric measurements was done with an ANOVA using a Bonferroni-Dunn correction. RESULTS: Tensiometric measurements of the mucosa were increased over normal controls when the surgical technique resulted in mucosal disruption. When the surgical technique resulted in primarily muscle disruption (radiofrequency) tensiometric measurements of the muscle were increased over controls. Histological analysis demonstrated normal remucosalization in all specimens, with fibrosis increased at the site of the primary injury. CONCLUSIONS: The type of injury produced resulted in identifiable patterns of physiological and histological change. Understanding of the effects of available surgical techniques is important in guiding our choice of surgical approach and allows us to better counsel our patients on their surgical options.     

Operative techniques of uvulopalatopharyngoplasty

Uvulopalatopharyngoplasty is, for the most part, both safe and effective as a surgical treatment for obstructive sleep apnea and severe snoring. Most complications can be avoided with proper surgical technique. Palatal dysfunction can be avoided if the shortening of the soft palate in the midline (uvula) area is minimized. Nasopharyngeal stenosis can be avoided with minimization of the posterior pillar resection and by avoidance of pharyngeal undermining. The effectiveness of surgery can be improved by placing emphasis 1) on opening the nasopharynx widely in the lateral port areas and 2) on tissue removal deep in the inferior tonsillar poles (and hypopharynx) with mucosal advancement and suturing.     

Contemporary Surgery for Obstructive Sleep Apnea Syndrome

Surgical treatment of obstructive sleep apnea syndrome (OSAS) has been available in some form for greater than three decades. Early management for airway obstruction during sleep relied on tracheotomy which although life saving was not well accepted by patients. In the early eighties two new forms of treatment for OSAS were developed. Surgically a technique described as a uvulopalatopharyngoplasty (UPPP) was used to treat the retropalatal region for snoring and sleep apnea. Concurrently sleep medicine developed a nasal continuous positive airway pressure (CPAP) device to manage nocturnal airway obstruction. Both of these measures were used to expand and stabilize the pharyngeal airway space during sleep. The goal for each technique was to limit or alleviate OSAS. Almost 30 yr later these two treatment modalities continue to be the mainstay of contemporary treatment. As expected, CPAP device technology improved over time along with durable goods. Surgery followed suit and additional techniques were developed to treat soft and bony structures of the entire upper airway (nose, palate and tongue base). This review will only focus on the contemporary surgical methods that have demonstrated relatively consistent positive clinical outcomes. Not all surgical and medical treatment modalities are successful or even partially successful for every patient. Advances in the treatment of OSAS are hindered by the fact that the primary etiology is still unknown. However, both medicine and surgery continue to improve diagnostic and treatment methods. Methods of diagnosis as well as treatment regimens should always include both medical and surgical collaborations so the health and quality of life of our patients can best be served.     

Site of upper airway obstruction in patients with idiopathic obstructive sleep apnea

We developed a technique to determine the site of upper airway obstruction in patients with idiopathic obstructive sleep apnea (OSA). This technique is based on the analysis of inspiratory airflow pressures at various levels of the pharyngeal airway during sleep. Pharyngeal pressure was measured by a moveable Millar catheter pressure transducer. The catheter's position in the airway was localized radiographically. Ten patients with OSA were tested: five patients were found to have upper airway obstruction at the level of the soft palate, and five had upper airway obstruction at the base of the tongue. We concluded that measuring airway pressures at multiple sites along the airway is useful in localizing the site of obstruction in patients with OSA, and may have important implications in terms of the patient's response to surgical treatment.     

The effect of radiofrequency volumetric tissue reduction of soft palate on voice

The surgical techniques used for snoring and OSA treatment include partial/complete resection or tissue reduction of the oropharyngeal structures such as uvula, tonsilla palatinas, soft palate, lateral pharyngeal tissues and tongue base. So it is predictable for these techniques to affect the resonating volume of the vocal tract and therefore the speech sounds. The goal of this study was to evaluate whether radiofrequency volumetric tissue reduction (RFVTR) of the soft palate can cause voice changes by altering the formant frequencies and fundamental frequency of vowels. A prospective study of 26 habitual snorers and mild obstructive sleep apnea patients (apnea–hypopnea index, <10 in all cases) were investigated before and 6 weeks after RFVTR. The patients received one Somnoplasty® RFVTR treatment of 1,400 J per treatment session: 700 J into the midline and 350 J on each side of the soft palate with a maximum temperature of 80°C. Acoustic evaluation was made by the Multidimensional Voice Program. The mean fundamental frequency (MF0) and the first three formant frequencies (F1, F2, F3) of four sustained vowels /a/, /e/, /i/ and /o/ were determined. Comparison between preoperative and postoperative acoustic analysis of the MF0 and F1, F2, F3 of sustained vowels revealed no significant change. The findings of the study indicate that RFVTR of the soft palate as a treatment for snoring and mild forms of OSA does not have a significant impact on the mean fundamental frequency and formant frequencies of vowels. These results seem to be important in management of patients with concerns about postoperative vocal quality, such as singers and professional speakers.     

Laryngeal obstruction and obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome has been studied intensively since it was introduced in the 1970's; these studies have shown that the site of upper airway obstruction appears to vary among patients. Snoring is typically defined as the sound created by rhythmic oscillations of the soft palate in the inspiratory air stream during sleep. Snoring occurs in 100% of patients with obstructive sleep apnea and, for selected patients, is treatable by surgery. Snoring can, however, mean different things to different patients and physicians. Five atypical cases of obstructive sleep apnea syndrome are presented in which laryngeal dysfunction played a role in producing symptoms of obstructive sleep apnea syndrome. Recording nocturnal sounds during sleep and examining the entire upper respiratory tract may be important in determining appropriate medical or surgical management.     

Modified uvulopalatopharyngoplasty: The extended uvulopalatal flap

OBJECTIVE: To investigate the surgical outcomes of a modified uvulopalatopharyngoplasty-extended uvulopalatal flap in the treatment of obstructive sleep apnea.Material and methods: Thirty-three consecutive patients with obstructive sleep apnea underwent extended uvulopalatal flap that consisted of bilateral tonsillectomy, dissection and removal of submucosal adipose tissue of the soft palate and supratonsillar area; imbrication; and reposition of the denuded uvulopalatal flap. Variables of polysomnography included the respiratory disturbance index, snoring index, and minimal oxygen saturation. Surgical success was defined as achieving the postoperative respiratory disturbance index to less than 20 events per hour and a greater than 50% reduction of the preoperative respiratory disturbance index. RESULTS: Six months after operation, 27 patients (81.8%) responded successfully. The mean respiratory disturbance index decreased from 41.6 +/- 28.2 to 12.5 +/- 18.1(P <.0001), and the mean minimal oxygen saturation and snoring index improved significantly (P <.0001). The postoperative sequelae were mild with 3% of occasional nasal regurgitation. CONCLUSIONS: The results in this series revealed that extended uvulopalatal flap improves obstructive sleep apnea with minimal adverse effect in selected patients, and this technique suggests a role of fat dissecting in the palatal surgery for obstructive sleep apnea.     

软硬腭前移鼻咽下口扩大术初步报告

目的：运用软硬腭前移的手术方法扩大鼻咽下口，改善因鼻咽部狭小致阻塞性睡眠呼吸暂停综合征患者的呼吸暂停症状。方法：手术切除硬腭后份使其缩短、悬雍垂软腭成形并将软腭拉向前，扩大鼻咽下口。结果：患者术后自觉症状及客观评价疗效满意。结论：软硬腭前移鼻咽下口扩大显著改善鼻咽下口狭小导致的阻塞性睡眠呼吸暂停患者的症状。     

低温等离子射频治疗阻塞性睡眠呼吸暂停低通气综合征60例

目的 探讨低温等离子射频减容（RFA）治疗阻塞性睡眠呼吸暂停低通气综合征（OSAHS）的临床方法和疗效。方法 采用ENTec CobatorTM手术系统治疗仪和 一次性Reflex45、Reflex55刀头,对60例OSAHS患者肥厚的下鼻甲、软腭、悬雍垂、咽侧索及舌根等进行黏膜下打孔减容手术（RFA）。术中根据患者的阻塞部位不同而采取不同的手术方法,变应性鼻炎患者并行抗过敏治疗。手术均在局麻下进行。结果 所有患者术中、术后无明显并发症发生。手术后6个月、12个月呼吸暂停低通气指数（AHI）最低血氧饱和度（LSaO2）指标均明显改善（P＜0.01）,手术后软腭、舌根部体积较术前明显缩小,咽腔扩大,症状明显减轻 或消失,呼吸暂停次数明显减少,白天嗜睡消失或基本消失,精力充沛。按照OSAHS诊断依据和疗效评定标准,6个月后治愈18例,显效28例,有效10例,无效4例,总有效率为93.33%;12个月后治愈15例,显效25例,有效13例,无效7例,总有效率为88.33%;轻度较中重度有效率高（分别为100%,67.3%）。结论 低温等离子射频减容（RFA）治疗阻塞性睡眠呼吸暂停低通气综合征（OSAHS）简便、省时、无并发症,患者易接受且可重复治疗,临床疗效确切,值得临床推广,但其远期疗效尚有待观察和探讨。     

The roles of the anterior tonsillar pillar and previous tonsillectomy on sleep-disordered breathing

We conducted a study to determine if there is a correlation between inadequate anterior tonsillar pillar support and sleep-disordered breathing. We examined 11 patients with a history of tonsillectomy to ascertain the structural and functional integrity of their anterior tonsillar pillars. All 11 demonstrated a loss of anterior pillar support and collapse of their soft palate to the extent that the soft palate passively pressed against the posterior pharyngeal wall. We conclude that a deficiency of anterior tonsillar pillar support does indeed predispose patients to obstructive sleep apnea syndrome. Knowledge of this correlation can help guide the method of surgical treatment and should reinforce the need to maintain the integrity of the anterior tonsillar pillars.     

The results of the surgical treatment of obstructive sleep apnea syndrome with the use of the cold plasma technique

A total of 110 patients presenting with rhonchus and obstructive sleep apnea syndrome (OSAS) have been given surgical treatment since 2005; 88 of them have undergone cold-plasma nucleoplasty. The study has demonstrated the beneficial effect of coblation surgery on the soft palate, low risk of complications, small number of adverse reactions, and good tolerability of the surgical procedure shown by the patients.     

Determination of obstructive site in obstructive sleep apnea

Patients with obstructive sleep apnea syndrome (OSAS) may have airway obstruction at various levels, including the uvula-soft palate complex, base of tongue, and/or possibly other sites. For patients with tongue base and/or laryngeal obstruction, uvulopalatopharyngoplasty (UPPP, ppp) will not alleviate the obstruction. Prior authors have proposed that the hyoid bone position as determined by cephalometric x-rays can predict which patients have obstruction at a lower site than the soft palate. In this study, patients with obstructive sleep apnea syndrome were evaluated with polysomnographic testing, fiberoptic endoscopy, and cine-CT scans (Imatron Scanner with multiple level rapid sequence scans) in an attempt to determine precisely the site of airway obstruction. Measurements of airway size taken at the time of fiberoptic pharyngoscopy were compared with those determined by the cine-CT studies. Initial results revealed that fiberoptic pharyngoscopy in the sitting and supine positions was helpful in confirming pharyngeal airway sites with smaller diameters in awake patients. However, the cine-CT exam performed in both sleeping and awake states provided more direct data regarding the airway during sleep. We feel that with more clinical experience the cine-CT technique will prove to be the most helpful study for identification of the obstructive airway site in obstructive sleep apnea syndrome.     

Histopathology of the uvula and the soft palate in patients with mild, moderate, and severe obstructive sleep apnea

OBJECTIVE: To study morphometric and qualitative histopathologic changes of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea. STUDY DESIGN: A prospective, nonrandomized controlled study. METHODS: The distal soft palate and uvula were excised during uvulopalatopharyngoplasty from 34 male patients with obstructive sleep apnea. Control specimens were retrieved from 7 male cadavers with no related disorders. All specimens underwent routine processing and the mid-sagittal sections were studied. Morphometric analysis of the relative proportions of the tissue constituents was carried out. Also, a qualitative assessment was performed to detect possible pathologic changes. RESULTS: The body mass index of patients was significantly higher from that of control subjects. The area fraction occupied by the tissue constituents of the distal portion of the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea and in control subjects was similar, with small and insignificant differences regarding the contents of glands, muscle, fat, blood vessels, and the epithelium. Only the connective tissue was significantly greater in patients with moderate obstructive sleep apnea than in those with severe obstructive sleep apnea and control subjects. The qualitative assessment of the specimens disclosed normal tissue architecture without evidence of destruction. Vascular engorgement, fibrosis, edema, inflammatory cell infiltration, and dilated glandular ducts were observed in a portion of patients and control subjects. CONCLUSIONS: The structure of the distal soft palate and uvula of patients with obstructive sleep apnea undergoes insignificant changes and is independent of the body mass index levels, indicating that the pathologic changes are probably the sequela of airway obstruction rather than its cause.     

悬雍垂—软腭折叠成形术治疗阻塞性睡眠呼吸暂停低通气综合征

OBJECTIVE: To explore the effect of the modified (Uvulopalatopharyngoplasty, UPPP) where uvula is reserved completely and the soft palate is folded in the operation. METHODS: 36 patients with the obstructive sleep apnea-hypopnea syndrome (OSAHS) (30 men, 6 women) underwent operation. The uvula and the muscles of the soft palate were reserved completely, and the soft palate was folded during the operation. RESULTS: 31 patients (86.1%) reported improvement of snoring and daytime somnolence. 30 patients (83.33%) showed a decrease of at least 50% in the apnea and hypopnea indices (AHI). No velopalatal insufficiency occurred. CONCLUSION: The modified UPPP not only enlarges pharyngeal cavity, but also avoids the postoperative complications. The modified UPPP could be better than the traditional operation.     

Retropalatal Airway Characteristics in Uvulopalatopharyngoplasty Compared With Transpalatal Advancement Pharyngoplasty

Uvulopalatopharyngoplasty (UPPP) is reported successful in treatment of obstructive sleep apnea for approximately 50% of patients. Several modifications of the procedure have been described, including transpalatal advancement pharyngoplasty, which resects a portion of posterior hard palate and advances the soft palate anteriorly. Comparing effectiveness of different techniques based on sleep and respiratory data is confounded by multiple variables including clinical failure at nonsurgical sites and imprecise patient selection techniques. Since pharyngeal surgical procedures prevent collapse and obstruction by structurally modifying the upper airway, measuring structural changes in size and collapsibility provides a method to compare techniques. To evaluate whether transpalatal advancement pharyngoplasty is more effective in modifying upper airway characteristics than UPPP, upper airway cross-sectional size and collapsibility were measured after UPPP and transpalatal advancement pharyngoplasty. Six patients were evaluated using a quantitative endoscopic technique. After transpalatal advancement pharyngoplasty maximal retropalatal airway size increased 321% from 29.7 ± 9.9 to 95.3 ± 16 mm² (P < 0.01), and retropalatal closing pressure decreased from 4.7 ± 1.6 to -3.8 ± 0.7 cm/H₂O (P < 0.01) compared with UPPP. Respiratory disturbance index decreased from 74.5 ± 13.5 to 29.2 ± 9 events/hour postoperatively (P < 0.05). Results support the conclusion that transpalatal advancement pharyngoplasty increases retropalatal size and decreases retropalatal collapsibility compared with UPPP. Since these characteristics are postulated to contribute to increased stability during sleep, transpalatal advancement pharyngoplasty may potentially improve UPPP outcome in selected patients with small retropalatal airway areas after traditional surgery.